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:
829	2022-01-11 11:03	Anonymous (not verified)	173.22.78.156	Marr Arnold Planning, LLC	Limited Liability Company	1328 California Ave, Ames, IA 50014	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-11	Summer Marr	summer@marrarnoldplanning.com	Ames	Story	IA	Beth Skluzacek	Kris Evans	Signed	(1) The employer does not elect the employers’ liability coverage.	Summer Marr	summer@marrarnoldplanning.com	owner	Ames	Story	IA	Beth Skluzacek	Kris Evans	Signed
518	2021-05-12 19:22	Anonymous (not verified)	184.105.50.148	Angela Smith and Christopher Smith	Proprietorship	2321 130th Street Belmond, IA 50421	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-08	Christopher Lynn Smith	1angismith@gmail.com	Belmond	Wright	Iowa	Betty Warrington	Nicholas Mehmen	Signed	(1) The employer does not elect the employers’ liability coverage.	Angela Kay Smith	1angismith@gmail.com	Wife	Belmond	Wright	Iowa	Betty Warrington	Nicholas Mehmen	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
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
1350	2022-10-31 10:42	Anonymous (not verified)	108.160.48.9	gaes trucking	Proprietorship	84642 Dun Rd Norfolk, NE 68701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	SHANE GAES	scgaes@icloud.com	Norfolk	NE	United States	Bill Rich	Ben Becker	Signed	(1) The employer does not elect the employers’ liability coverage.	shane gaes	scgaes@icloud.com	self	norfolk	pierce county nebraska	nebraska	Bill Rich	Ben Becker	Signed
1830	2023-09-08 11:45	Anonymous (not verified)	94.188.205.177	Bradley A Sneeden	Proprietorship	36 Sunset Drive, Beardstown, IL 62618	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-08	Bradley A Sneeden	bradsneeden@gmail.com	Beardstown	Cass	IL	Billie Sneeden	Dillon McNeff	Signed	(1) The employer does not elect the employers’ liability coverage.	Bradley A Sneeden	bradsneeden@gmail.com	Self	Beardstown	Cass	IL	Billie Sneeden	Dillon McNeff	Signed
272	2020-10-02 13:10	Anonymous (not verified)	99.203.92.229	Batres Homes Renovation LLC	Limited Liability Company	3000 2nd Ave Des Moines Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-02	Gabriel Antonio Batres Huezo	gabirlebatres7@gmail.com	Des Moines	Polk	Iowa	Blanca Silvia Leiva	Luis Mariano	Signed	(1) The employer does not elect the employers’ liability coverage.	Walter Alexander Batres Huezo	wbatres12@gmail.com	Employer	Des Moines	Polk	Iowa	Blanca Silvia Leiva	Luis Mariano	Signed
2100	2024-03-17 12:36	Anonymous (not verified)	94.188.205.167	Donovan Electric LLC	Limited Liability Company	857 Tipperary rd Iowa City iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-17	Bill Donovan	bill@donovanelectricllc.com	Iowa City	Johnson	IA	Bo Nock	Stephanie Ineichen	Signed	(1) The employer does not elect the employers’ liability coverage.	Blake Donovan	blaked@donovanelectricllc.com	Partner	Iowa City	Johnson	IA	Bo Nock	Stephanie Ineichen	Signed
230	2020-08-13 16:59	Anonymous (not verified)	174.217.21.76	Aaron Gilbert	Proprietorship	11864 W 125th St S, Runnells, IA 50237	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-13	Aaron Michael Gilbert	gilbertinpc@msn.com	Runnells	Jasper	Iowa	Bob Coluzzi	Mitch Coluzzi	Signed	(1) The employer does not elect the employers’ liability coverage.	Aaron Michael Gilbert	gilbertinpc@msn.com	Same person	Runnells	Jasper	Iowa	Bob Coluzzi	Mitch Coluzzi	Signed
2147	2024-04-12 11:52	Anonymous (not verified)	94.188.205.166	Tri County Enterprise	Partnership	5527 Crane Lane NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-12	Ken McGraw	kenmcgraw1974@gmail.com	Center Point	IA	United States	bob nissen	Jenny Vaske	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Ashlock	brian@tricounty-iowa.com	General Manager	Shellsburg	IA	United States	bob Nissen	Jenny Vaske	Signed
610	2021-08-18 11:15	Anonymous (not verified)	172.58.84.99	LeafFilter North LLC	Partnership	866 40th ave bettendorf iowa 52722	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-18	Thomas R Fuller	tomstl001@yahoo.com	DAVENPORT	Iowa	Iowa	Bob phillips	Julie fuller	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan nisiewicz	jnisiewicz@leafhome.com	Regional field recruiter	Bettendorf iowa	Scott	Iowa	Warren crow	Jordan lloyd	Signed
1907	2023-11-15 09:45	Anonymous (not verified)	94.188.205.168	Dan Taylor	Proprietorship	1422 State ST.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-15	Daniel Taylor	mailrunner1958@gmail.com	Mason City	Cerro Gordo	IA	Bob Smith	Dave Clark	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Taylor	mailrunner1958@gmail.com	employee	Mason City	Cerro Gordo	IA	Bob Smith	Dave Clark	Signed
141	2020-04-28 10:14	Anonymous (not verified)	74.84.101.138	Lutheran Cemetery Association	Proprietorship	410 S. Mechanic Street Decorah, IA 52101	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-02	Steven Matter	chelsea.whalen@upperiowains.com	Decorah	Winneshiek	IA	Bobbi Jo Berg	Robin C Schultz	Signed	(1) The employer does not elect the employers’ liability coverage.	Steven Matter	chelsea.whalen@upperiowains.com	Secretary	Decorah	Winneshiek	IA	BOBBI JO BERG	Robin C Schultz	Signed
2079	2024-03-06 18:59	Anonymous (not verified)	94.188.205.166	Maple Leaf Landscape Maintenance	Proprietorship	309 E. Exchange St Geneseo IL 61254	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-05	Chris Walters	Mapleleaf@mapleleaflawnsolutions.com	GENESEO	IL	United States	Bobbi Jo Cox	Victor Snook	Signed	(1) The employer does not elect the employers’ liability coverage.	Chris Walters	mapleleaf@mapleleaflawnsolutions.com	Self	GENESEO	IL	United States	Bobbi Jo Cox	Victor Snook	Signed
1654	2023-05-19 11:09	Anonymous (not verified)	94.188.205.176	ST SULLIVAN CONSTRUCTION COMPANY	Proprietorship	1614 100TH ST., OELWEIN, 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.	2023-05-19	STEVE SULLIVAN	sullycon@msn.com	Oelwein	Fayette	Iowa	Bobbie J Bergan	Shelby Williams	Signed	(1) The employer does not elect the employers’ liability coverage.	STEVE SULLIVAN	sullycon@msn.com	OWNER	OELWEIN	FAYETTE	IOWA	BOBBIE J BERGAN	SHELBY WILLIAMS	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
1707	2023-06-25 10:39	Anonymous (not verified)	94.188.207.224	Michael D Ray	Proprietorship	4944 Holcomb 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.	2023-06-22	Michael D Ray Jr	mdray01@msn.com	Des Moines	Polk	Iowa	Bonnie R Finken	Isaiah O Washington	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael D Ray	mdray01@msn.com	Owner Proprietor	Des Moines	Polk	Iowa	Bonnie R Finken	Isaiah O Washington	Signed
2030	2024-02-07 10:10	Anonymous (not verified)	94.188.207.227	Jason Jacobs	Proprietorship	115 West 7th St., Suite 1W, Spencer, IA 51301	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-07	Jason Jacobs	jason.jacobs@thrivent.com	Spencer	Clay	Iowa	Brad Bernardy	Emily Jacobs	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Jacobs	jason.jacobs@thrivent.com	Self	Spencer	Clay	Iowa	Brad Bernardy	Emily Jacobs	Signed
1635	2023-05-10 07:25	Anonymous (not verified)	94.188.205.166	Chris Hay	Proprietorship	4911 Sutliff Rd 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.	2023-05-10	Christopher A Hay	hay2u2@windstream.net	Solon	Johnson	Iowa	Brad Bower	Kirk Strunk	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher Hay	hay2u2@windstream.net	Self	Solon	Johnson	Iowa	Brad Bower	Kirk Strunk	Signed
1644	2023-05-12 07:59	Anonymous (not verified)	94.188.205.176	Blue Ribbon Drywall	Proprietorship	3025 Peaceful Dr Riverside, IA 52327	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-12	Seth Mize Sr	stmize@hotmail.com	Riverside	Washington	Iowa	Brad Bower	Chris Hay	Signed	(1) The employer does not elect the employers’ liability coverage.	Seth Mize Sr	stmize@hotmail.com	Self	Riverside	Washington	Iowa	Brad Bower	Chris Hay	Signed
1645	2023-05-12 14:48	Anonymous (not verified)	94.188.207.225	VL Drywall LLC	Limited Liability Company	1608 6th Ave SE Cedar Rapids	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-12	LESLIE LEYVA	lleyva9696@gmail.com	Cedar Rapids	LINN	Iowa	Brad Bower	Chris Hay	Signed	(1) The employer does not elect the employers’ liability coverage.	Leslie Leyva	lleyva9696@gmail.com	Self	Cedar Rapids	Linn	Iowa	Chris Hay	Brad Bower	Signed
1648	2023-05-16 08:16	Anonymous (not verified)	94.188.205.169	Hernandez Drywall	Proprietorship	2001 8th St Coralville, IA 52241	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-16	Gerardo Hernandez	gerardohernandez56u@gmail.com	Coralville	Johnson	Iowa	Brad Bower	Kirk Strucnk	Signed	(1) The employer does not elect the employers’ liability coverage.	Gerardo Hernandez	gerardohernandez56u@gmail.com	Self	Coralville	Johnson	iowa	Brad Bower	Kirk Strunk	Signed
1679	2023-06-06 08:27	Anonymous (not verified)	94.188.205.174	Remys Drywall LLC	Proprietorship	42 Hoover Blvd West Branch, IA 52358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-06	Remigio M Juan	remmateojuan1997@gmail.com	West Branch	Cedar	IA	Brad Bower	Chris Hay	Signed	(1) The employer does not elect the employers’ liability coverage.	Remigio M Juan	remmateojuan1997@gmail.com	Self	West Branch	Cedar	IA	Brad Bower	Chris Hay	Signed
1969	2023-12-28 15:46	Anonymous (not verified)	94.188.205.176	Beau Vander Sluis	Proprietorship	3000 Seneca 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.	2023-12-28	Beau Vander Sluis	beauvsluis@gmail.com	Des Moines	Polk	United States	Braden Banning	Andrew Behanish	Signed	(1) The employer does not elect the employers’ liability coverage.	Beau Vander Sluis	beauvsluis@gmail.com	Same	Des Moines	Polk	United States	Braden Banning	Andrew Behanish	Signed
1003	2022-03-23 13:06	Anonymous (not verified)	24.149.3.190	Thomas Wedmore	Proprietorship	200 State St, Ste 202G, Cedar Falls, IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-23	Thomas Wedmore	twedmore@phillipsstafford.com	Cedar Falls	IA	United States	Bradley Phillips	Joshua Stafford	Signed	(1) The employer does not elect the employers’ liability coverage.	Thomas Wedmore	twedmore@phillipsstafford.com	Self	Reinbeck	Grundy	IA	Bradley Phillips	Joshua Stafford	Signed
545	2021-06-22 12:58	Anonymous (not verified)	97.88.95.170	Peter L. Viscusi	Proprietorship	328 Jones Avenue, Warrensburg, MO 64093	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-06-22	Peter L. Viscusi	pviscusi@charter.net	Warrensburg	Johnson	Missouri	Bradley S. McGuffey	Randel C. Kyle	Signed	(1) The employer does not elect the employers’ liability coverage.	Peter L. Viscusi	pviscusi@charter.net	Self	Warrensburg	Johnson	Missouri	Bradley S. McGuffey	Randel C. Kyle	Signed
1179	2022-07-05 12:21	Anonymous (not verified)	173.18.233.175	Crossline Contracting LLC	Limited Liability Company	2009 Wilson Ave SW, Cedar Rapids, IA 52404	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-05	Adam Anderson	crosslinecontracting319@gmail.com	Ryan, IA	Deleware	Iowa	Branden Peters	Todd Philpott	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Crossline Contracting LLC	crosslinecontracting319@gmail.com	Self	Ryan Iowa	Deleware	Iowa	Branden Peters	Todd Philpott	Signed
89	2020-03-13 12:41	Anonymous (not verified)	216.96.113.16	B’s Sweet Treats	Proprietorship	123 E Marion St. Sigourney IA 52591	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-13	Brandi Wehr	brndwehr54@hotmail.com	Sigourney	Keokuk	IA	Brandi	Brandi	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandi Wehr	brndwehr54@hotmail.com	Same	Sigourney	Keokuk	IA	Brandi	Brandi	Signed
1916	2023-11-21 12:31	Anonymous (not verified)	94.188.205.174	DC Painting	Proprietorship	205 Astor 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.	2023-11-03	Damion Clement	gcort06@gmail.com	Des Moines	Polk	IA	Brandi Haight	Dennis Clement	Signed	(1) The employer does not elect the employers’ liability coverage.	Damion Clement	gcort06@gmail.com	Owner	205 Astor Street	Polk	IA	Brandi Haight	Dennis Clement	Signed
178	2020-06-08 13:51	Anonymous (not verified)	173.21.16.200	Daniel Mullanack	Limited Liability Company	1208 Franklin St. Buffalo, IA 52728	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2020-06-08	daniel mullanack	mullanackbuilders@mediacombb.net	buffalo	scott	iowa	brandon brooks	amy carlson	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	linda mullanack	mullanackbuilders@mediacombb.net	office manager	buffalo	scott	iowa	brandon brooks	amy carlson	Signed
1860	2023-10-04 14:31	Anonymous (not verified)	94.188.207.229	Raymond Osbon	Proprietorship	1634 Park Towne LN NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-04	Raymond Earl Osbon	rozbon999@gmail.com	Cedar Rapids	Linn	Iowa	Brandon Gibbs	Jamie Fisher	Signed	(1) The employer does not elect the employers’ liability coverage.	Raymond Earl Osbon	rozbon999@gmail.com	Myself	Cedar Rapids	Linn	Iowa	Brandon Gibbs	Jamie Fisher	Signed
519	2021-05-13 10:32	Anonymous (not verified)	50.82.22.159	Southern Iowa Crane, Incorporated	Proprietorship	635 Mill Street; Ottumwa, IA 52501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-13	Steve Lee	southerniowacraneinc@hotmail.com	Ottumwa	Wapello	Iowa	Brandon Gravett	Sarah Gravett	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Lee	sotherniowacraneinc@hotmail.com	Self	Ottumwa	Wapello	Iowa	Sarah Gravett	Brandon Gravett	Signed
1000	2022-03-23 10:24	Anonymous (not verified)	75.162.12.87	Eric Louvan	Proprietorship	2840 104th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-23	Eric Louvan	elouvan@phillipssstafford.com	Ankeny	Polk	Iowa	Brandon Johnson	Ann Louvan	Signed	(1) The employer does not elect the employers’ liability coverage.	Brad Phillips	bphillips@phillipsstafford.com	Employee	Urbandale	Polk	IA	Eric Louvan	Luke Vanroekel	Signed
647	2021-09-20 10:37	Anonymous (not verified)	173.29.34.49	Brandon Jones	Proprietorship	2043 3x Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-20	Brandon Dederick Jones	Kaleb0430jones@gmail.com	East Moline	United States	Illinois	Brandon Jones	Brandon Jones	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandon Dederick Jones	Kaleb0430jones@gmail.com	self	East Moline	United States	Illinois	Brandon Jones	Brandon Jones	Signed
1051	2022-04-14 17:56	Anonymous (not verified)	199.59.236.46	Triple M Welding	Proprietorship	407 4th St Sw	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-14	Matthew Gibson	matthew.gibson02003@gmail.com	Independence	Iowa	Iowa	Brandon Keener	Cody Laughlin	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Gibson	matthew.gibson02003@gmail.com	Owner	Independence	Iowa	Iowa	Brandon Keener	Cody Laughlin	Signed
1510	2023-03-09 10:57	Anonymous (not verified)	94.188.207.226	Sawyer Eblen	Proprietorship	14411 293rd Ave 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.	2023-03-09	Sawyer Eblen	sawyer.eblen@gmail.com	Belgrade	MN	United States	Brandon Keller	Mitchell Vetsch	Signed	(1) The employer does not elect the employers’ liability coverage.	Sawyer Eblen	sawyer.eblen@gmail.com	Owner	Belgrade	MN	United States	Brandon Keller	Mitchell Vetsch	Signed
101	2020-03-24 15:49	Anonymous (not verified)	161.69.123.10	Blair Lincoln	Proprietorship	32586 390th St Colesburg, IA 52035	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-24	Blair Alan Lincoln	balincoln@gmail.com	Colesburg	County	Iowa	Brandon Mather	Travis Ries	Signed	(1) The employer does not elect the employers’ liability coverage.	Blair Alan Lincoln	balincoln@gmail.com	Owner	Colesburg	County	IA	Brandon Mather	Travis Ries	Signed
97	2020-03-21 12:05	Anonymous (not verified)	173.22.82.137	JHK Construction LLC	Limited Liability Company	6203 Casey Court NE Cedar Rapids, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-21	Edward Charles Loehr	jhkconstruction10@gmail.com	Cedar Rapids	Linn County	Iowa	Brandon Peters	Mandy Mason	Signed	(1) The employer does not elect the employers’ liability coverage.	Edward Charles Loehr	jhkconstruction10@gmail.com	Owner	6203 Casey Court NE	Linn County	Iowa	Brandon Peters	Mandy Mason	Signed
921	2022-02-17 12:38	Anonymous (not verified)	173.22.55.191	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.	(1) I am not electing the employers’ liability coverage.	2022-02-17	Victor Holzworth	holzconstruction@gmail.com	Waukee	Dallas	Iowa	Brandon Pratt	Mariah Burgett	Signed	(1) The employer does not elect the employers’ liability coverage.	Victor Holzworth	holzconstruction@gmail.com	Owner	West Des Moines	Polk	Iowa	Brandon Pratt	Mariah Burgett	Signed
922	2022-02-17 12:44	Anonymous (not verified)	173.22.55.191	Red Rock Hunt Club	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.	(1) I am not electing the employers’ liability coverage.	2022-02-17	Victor Holzworth	holzconstruction@gmail.com	Waukee	Dallas	Iowa	Brandon Pratt	Mariah Burgett	Signed	(1) The employer does not elect the employers’ liability coverage.	Victor Holzworth	holzconstruction@gmail.com	Owner	West Des Moines	Polk	Iowa	Brandon Pratt	Mariah Burgett	Signed
923	2022-02-17 12:49	Anonymous (not verified)	173.22.55.191	Fat Bus	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.	(1) I am not electing the employers’ liability coverage.	2022-02-17	Victor Holzworth	holzconstruction@gmail.com	Waukee	Dallas	Iowa	Brandon Pratt	Mariah Burgett	Signed	(1) The employer does not elect the employers’ liability coverage.	Victor Holzworth	holzconstruction@gmail.com	Owner	West Des Moines	Polk	Iowa	Brandon Pratt	Mariah Burgett	Signed
665	2021-10-06 09:22	Anonymous (not verified)	192.96.173.171	Michael Childers	Proprietorship	21 N.6th street savanna Illinois	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-06	Michael Childers	peddler73@hotmail.com	Savanna	Carroll	Illinois	Brandy arnold	Jordan nisiewicz	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas city	Clay	Mo	Jordan nisiewicz	Brandy arnold	Signed
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
958	2022-03-08 20:17	Anonymous (not verified)	50.82.39.158	Ramos Drywall	Limited Liability Company	1355 Ozark Ridge, Coralville, IA 52241	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-03-08	Carlos Rene Ramos Martinez	carlosramos2345@gmail.com	Coralville	Iowa	United States	Breanna Barragan	Eliseo Tapia JR.	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Carlos Rene Ramos Martinez	carlosramos2345@gmail.com	N/A- Same Person	Coralville	Johnson County	IA	Breanna Barragan	Eliseo Tapia JR.	Signed
506	2021-05-10 09:29	Anonymous (not verified)	199.102.211.129	Nathan J Hurst LLC DBA J&K Construction	Limited Liability Company	3598 Orchard Rd. Osage, IA 50461	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-10	Nathan J Hurst	jkconstructionjake@yahoo.com	Osage	Mitchell	Iowa	Breanna Fox	Karl Herman	Signed	(1) The employer does not elect the employers’ liability coverage.	Breanna Fox	jkconstructionjake@yahoo.com	Office Manager	Osage	Mithell	Iowa	Nathan J Hurst	Karl F Herman	Signed
1723	2023-07-06 11:50	Anonymous (not verified)	94.188.205.175	Doug Ferneding	Proprietorship	21618 270th St. Carroll, IA 51401	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-06	Doug Ferneding	dougferneding@gmail.com	Carroll	Carroll	Iowa	Brenda Klein	Kyle Klein	Signed	(1) The employer does not elect the employers’ liability coverage.	Doug Ferneding	dougferneding@gmail.com	same	Carroll	Carroll	Iowa	Brenda Klein	Kyle Klein	Signed
1198	2022-07-11 15:46	Anonymous (not verified)	74.84.91.178	Dave's Remodeling LLC	Limited Liability Company	2308 Long Grove Ct, Dubuque, IA 52002	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-01	Kim Kern	davesremodeling@aol.com	Asbury	Dubuque	Iowa	Brenda Lewis	Gabe Drewlow	Signed	(1) The employer does not elect the employers’ liability coverage.	Kim Kern	davesremodeling@aol.com	co-owner	Asbury	Dubuque	Iowa	Brenda Lewis	Gabe Drewlow	Signed
1718	2023-06-29 12:36	Anonymous (not verified)	94.188.205.166	Aidan Obermueller	Proprietorship	2520 N Grandview Avenue, Dubuque, IA 52001	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-27	Aidan Obermueller	aidanobermueller@icloud.com	Dubuque	Dubuque	Iowa	Brenda Lewis	Sue Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Aidan Obermueller	aidanobermueller@icloud.com	self	Dubuque	Dubuque	Iowa	Brenda Lewis	Sue Miler	Signed
1641	2023-05-11 13:40	Anonymous (not verified)	94.188.207.228	Mike Weigel Construction, LLC	Limited Liability Company	2528 Dalton St, Ames IA 50010-1151	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-11	Michael Patrick Weigel	mikeweigelconstruction@gmail.com	Ames	Story	Iowa	Brenda Marie Weigel	Piper Rylee Weigel	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Patrick Weigel	mikeweigelconstruction@gmail.com	Self	Ames	Story	Iowa	Brenda Marie Weigel	Piper Rylee Weigel	Signed
930	2022-02-20 13:24	Anonymous (not verified)	174.198.77.72	2Maros Excavating Company	Limited Liability Company	204 West First Street, Saint Donatus, Iowa 52071	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-20	Steve Maro	2marosmfg@gmail.com	Saint Donatus	Jackson	Iowa	Brenda McKenna	Joe McKenna	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Maro	2marosmfg@gmail.com	Owner	Saint Donatus	Jackson	Iowa	Brenda McKenna	Joe McKenna	Signed
1371	2022-11-14 10:55	Anonymous (not verified)	166.181.86.95	Dean Abramczak	Proprietorship	524 Nodaway Dr center Point Iowa 52213	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-16	Dean Abramczak	gabramczak@gmail.com	Center Point	IA	United States	Brenda Oconner	Kenny McGraw	Signed	(1) The employer does not elect the employers’ liability coverage.	Dean Abramczak	gabramczak@gmail.com	I am the only employee I own the company	Center Point	IA	United States	Brenda Oconnner	Kenny McGraw	Signed
1120	2022-05-19 09:49	Anonymous (not verified)	65.125.92.130	JG Landscaping, LLC	Limited Liability Company	317 E 23rd St. Des Moines, IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-19	Javier Alexander Guzman	alexguz76@outlook.com	Des Moines	Polk	IA	Brenda Reedy	Chad Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Javier Alexander Guzman	alexguz76@outlook.com	Self	Des Moines	Polk	IA	Brenda Reedy	Chad Smith	Signed
1912	2023-11-16 08:40	Anonymous (not verified)	94.188.205.175	JC LANDSCAPING & LAWN CARE	Proprietorship	4940 E. SHERIDAN AVE 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.	2023-11-16	CLAUDIA TORO PINEDA	CLAUDIAMEP@HOTMAIL.COM	DES MOINES	POLK	IA	BRENDA REEDY	ADAM SMITH	Signed	(1) The employer does not elect the employers’ liability coverage.	CLAUDIA TORO PINEDA	CLAUDIAMEP@HOTMAIL.COM	SELF	DES MOINES	POLK	IA	BRENDA REEDY	ADAM SMITH	Signed
2218	2024-05-09 16:20	Anonymous (not verified)	94.188.205.167	Brenda Riseley	Proprietorship	2265 Copper Wynd Drive, Pleasant Hill Iowa 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.	2024-05-09	Brenda Riseley	riseleybrenda@gmail.com	Pleasant Hill	IA	United States	Brenda Riseley	Brenda Riseley	Signed	(1) The employer does not elect the employers’ liability coverage.	Brenda Riseley	riseleybrenda@gmail.com	Self	Pleasant Hill	IA	United States	David Bottino	Aubrey Stith	Signed
1195	2022-07-08 13:24	Anonymous (not verified)	174.198.67.66	Chapas Construction	Limited Liability Company	6424 Roseland 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.	2022-07-08	Polibio Raul Chapa Farez	chapasconstructionllc@gmail.com	Urbandale	IA	IA	Brenda Rivas	Charlie Chapa	Signed	(1) The employer does not elect the employers’ liability coverage.	Polibio Raul Chapa	chapasconstructionllc@gmail.com	President	Urbandale	IA	IA	Brenda Rivas	Charlie Chapa	Signed
1877	2023-10-23 15:49	Anonymous (not verified)	94.188.207.228	Craig Michael Wilson	Proprietorship	24538 118th Street, Columbus Junction, IA 52738	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-16	Craig Michael Wilson	tripod109@hotmail.com	Columbus Junction	Louisa	IA	Brenda Wilson	Ruger Dean	Signed	(1) The employer does not elect the employers’ liability coverage.	Craig Michael Wilson	tripod109@hotmail.com	Self	Columbus Junction	Louisa	IA	Brenda Wilson	Ruger Dean	Signed
662	2021-10-01 16:05	Anonymous (not verified)	174.242.224.18	Troy bryan	Limited Liability Company	2800 68th st urbandale Iowa 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-01	Troy bryan	tbryan0015@gmail.com	Urbandale	Polk	Iowa	Brenna painter	Marc bryan	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Troy bryan	tbryan0015@gmail.com	Owner	Urbandale	Polk	Iowa	Brenna painter	Marc bryan	Signed
1943	2023-12-06 16:34	Anonymous (not verified)	94.188.207.230	Your Neighbors Pressure Washing LLC	Limited Liability Company	2059 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.	2023-12-06	Alejandro Bacano Rodriguez	alejandrobacanorodriguez@gmail.com	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Alejandro Bacano Rodriguez	alejandrobacanorodriguez@gmail.com	Myself	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed
1944	2023-12-06 16:41	Anonymous (not verified)	94.188.207.226	Sell Now Iowa	Limited Liability Company	5525 Meredith Dr Suite B Des Moines, Iowa 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-06	Alejandro Bacano Rodriguez	alejandrobacanorodriguez@gmail.com	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Sale Now Iowa	team@sellnowiowa.com	None	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed
1945	2023-12-06 16:47	Anonymous (not verified)	94.188.205.169	Sell Now Iowa	Limited Liability Company	5525 Meredith Drive Suite B Des Moines Iowa 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-06	Alejandro Bacano Rodriguez	alejandrobacanorodriguez@gmail.com	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Sell Now Iowa	team@sellnowiowa.com	None	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed
1946	2023-12-06 16:51	Anonymous (not verified)	94.188.205.168	Blue Sky Renovations Iowa LLC	Limited Liability Company	2059 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.	2023-12-06	Alejandro Bacano Rodriguez	alejandrobacanorodriguez@gmail.com	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Sell Now Iowa	team@sellnowiowa.com	None	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed
1665	2023-05-27 17:41	Anonymous (not verified)	94.188.205.175	Diamond Spray Foam and Coatings LLC	Limited Liability Company	19024 345th St, Forest City, IA 50436	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-27	Joshua Gregory Diamond	dsfinsulation@gmail.com	Forest City	Winnebago	IA	Brett Busenitz	Bret Guggisburg	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua Gregory Diamond	dsfinsulation@gmail.com	Owner	Forest City	Winnebago	IA	Brett Busenitz	Bret Guggisburg	Signed
1083	2022-05-02 13:42	Anonymous (not verified)	173.18.233.175	John Helm	Proprietorship	417 Pleasant Hill DR Atkins, IA 52206	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-02	John Helm	johnhelmconstruction22@gmail.com	Atkins	Benton	Iowa	Brian Ashlock	Trevor Vick	Signed	(1) The employer does not elect the employers’ liability coverage.	John Helm	johnhelmconstruction22@gmail.com	Owner	Atkins	Benton	IOWA	Brian Ashlock	Trevor Vick	Signed
1879	2023-10-26 13:17	Anonymous (not verified)	94.188.207.224	CR Exteriors	Proprietorship	1636 Parktown Ct NE Unit 9	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-26	corey becker	cab222.ab@gmail.com	cedar rapids	linn	iowa	Brian Ashlock	Brian Coover	Signed	(1) The employer does not elect the employers’ liability coverage.	Corey Becker	cab222.ab@gmail.com	same	Cedar Rapids	Linn	Iowa	Brian Ashlock	Brian Coover	Signed
1983	2024-01-11 13:02	Anonymous (not verified)	94.188.205.168	r&k propety solutions	Proprietorship	po box 53 cedar rapids iowa 52406	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-11	roy rohwedder	rohwedder.roy@yahoo.com	Cedar Rapids	linn	ia	Brian Ashlock	tim vaske	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Ashlock	brian@tricounty-iowa.com	General Manager	Center Point	Benton	ia	Tim Vaske	Roy Rohwedder	Signed
920	2022-02-17 10:15	Anonymous (not verified)	208.81.192.69	Wapsie Valley Construction, LLC	Limited Liability Company	1154 Dennison Avenue, Fairbank, IA 50629	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-17	Merle B. Miller	accounting@robertseddy.com	Fairbank	Buchanan	Iowa	Brian C. Eddy	Samantha J. Stelter	Signed	(1) The employer does not elect the employers’ liability coverage.	Merle B. Miller	accounting@robertseddy.com	Same person	Fairbank	Buchanan	Iowa	Brian C. Eddy	Samantha J. Stelter	Signed
924	2022-02-17 13:02	Anonymous (not verified)	208.81.192.69	Wapsie Valley Construction, LLC	Limited Liability Company	1154 Dennison Ave., Fairbank, IA 50629	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-17	Henry O. Miller	accounting@robertseddy.com	Fairbank	Buchanan	Iowa	Brian C. Eddy	Samantha J. Stelter	Signed	(1) The employer does not elect the employers’ liability coverage.	Merle Miller	accounting@robertseddy.com	Same person	Fairbank	Buchanan	Iowa	Brian C. Eddy	Samantha J. Stelter	Signed
925	2022-02-17 13:07	Anonymous (not verified)	208.81.192.69	Wapsie Valley Construction, LLC	Limited Liability Company	1154 Dennison Ave., Fairbank, IA 50629	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-17	Chester H. Borntrager	accounting@robertseddy.com	Hazleton	Buchanan	Iowa	Brian C. Eddy	Samantha J. Stelter	Signed	(1) The employer does not elect the employers’ liability coverage.	Merle Miller	accounting@robertseddy.com	Same person	Fairbank	Buchanan	Iowa	Brian C. Eddy	Samantha J. Stelter	Signed
1402	2022-12-28 16:35	Anonymous (not verified)	208.69.145.91	DeRonde Flooring Inc.	Proprietorship	3612 NW 178th 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.	2022-12-28	Brian DeRonde	derondeflooring@gmail.com	Clive	Dallas	IA	Brian DeRonde	Courtney DeRonde	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian DeRonde	derondeflooring@gmail.com	Self	Clive	Dallas	IA	Brian DeRonde	Courtney DeRonde	Signed
1782	2023-08-04 08:04	Anonymous (not verified)	94.188.207.229	Matt Larson Construction	Limited Liability Company	1208 Hazel St. Pella, IA 50219	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-04	Matthew Mark Larson	larson-m@hotmail.com	Pella	Marion	IA	Brian Huddle	Jon E. Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Jon E. Miller	stmarypella@iowatelecom.net	Parish Secretary	Pella	IOWA	United States	Brian Huddle	Jon E. Miller	Signed
444	2021-03-22 16:26	Anonymous (not verified)	207.191.204.10	Robert G. Wright Jr,	Proprietorship	2721 Elm St Dubuque, IA 52001 PO Box 475 Dubuque, IA 52004	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-20	Robert G. Wright Jr,	robertw1963@gmail.com	Dubuque	Dubuque	Iowa	Brian Kregal	Lynda Howell	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert G. Wright Jr,	robertw1963@gmail.com	Owner	Dubuque	Dubuque	Iowa	Brian Kregel	Lynda Howell	Signed
331	2020-12-03 10:19	Anonymous (not verified)	174.213.165.124	TTC Cleaning Services	Limited Liability Company	2155-230th St Marshalltown, IA. 50158	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-12-03	Zachary Stephen Bolar	zbolar80@gmail.com	Marshalltown	Marshall	IA	Brian Mason	Casey Jesina	Signed	(1) The employer does not elect the employers’ liability coverage.	Zachary Stephen Bolar	zbolar80@gmail.com	Self	Marshall	Marshall	IA	Brian Mason	Casey Jesina	Signed
261	2020-09-17 15:52	Anonymous (not verified)	65.127.131.118	Jesus Adrian Martinez	Proprietorship	1517 Searle St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-17	Jesus Adrian Martinez	adrianmartinezventura21@gmail.com	Des Moines	Polk	Iowa	Brian Pruitt	Martin Pinon	Signed	(1) The employer does not elect the employers’ liability coverage.	Jesus Adrian Martinez	adrianmarinezventura21@gmail.com	self	Des Moines	Polk	Iowa	Brian Pruitt	Martin Pinon	Signed
552	2021-06-29 14:55	Anonymous (not verified)	97.125.35.240	Melo Drywall	Proprietorship	7500 Bloomfield Road Lot 78 Des Moines, Iowa 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-06-25	Marlene Bautista	bbautistamarbb@gmail.com	Des Moines	Polk	Iowa	Brian Pruitt	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Marlene Bautista	bbautistamarbb@gmail.com	self	Des Moines	Polk	Iowa	Brian Pruitt	Kelly Denger	Signed
350	2021-01-04 09:35	Anonymous (not verified)	173.29.234.11	Plum Communications, LLC	Limited Liability Company	1018 NW Campus Ridge CT, Ankeny, IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-01	Brian Shearer	brian@plumllc.com	Ankeny	Polk	IA	Brian Shearer	Brian Shearer	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Shearer	brian@plumllc.com	Owner	Ankeny	Polk	IA	Brian Shearer	Brian Shearer	Signed
823	2022-01-05 16:35	Anonymous (not verified)	173.29.232.165	Plum Communications, LLC	Limited Liability Company	1018 NW Campus Ridge CT, Ankeny, IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-01	Brian Shearer	brian@plumllc.com	Ankeny	Polk	Iowa	Brian Shearer	Brian Shearer	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Shearer	brian@plumllc.com	Owner	Ankeny	Polk	IA	Brian Shearer	Brian Shearer	Signed
265	2020-09-21 14:41	Anonymous (not verified)	74.84.65.174	Nagol Enterprises	Limited Liability Company	16124 PLEASANT 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.	2020-09-21	Logan Victor Ante	antelogan@gmail.com	Story CIty	Story	iowa	Brian Wade Warren	Tyler Christian Thompson	Signed	(1) The employer does not elect the employers’ liability coverage.	Logan Victor Ante	antelogan@gmail.com	Same	Story CIty	IA	IA	Brian Wade Warren	Tyler Christian Thompson	Signed
378	2021-01-29 11:43	Anonymous (not verified)	50.82.21.136	GRAPHIX MASTERS	Limited Liability Company	420 Hamilton St.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-01-29	Klayton Karl Kirkpatrick	klay@graphixmasters.us	Ottumwa	IA	United States	Brian Wilson	Aimee Kirkpatrick	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Klayton Kirkpatrick	klay@graphixmasters.us	Same	Ottumwa	Iowa	United States	Brian Wilson	Aimee Kirkpatrick	Signed
689	2021-10-25 14:38	Anonymous (not verified)	107.197.114.249	Brookstin Flooring LLC	Limited Liability Company	1702 Brown Deer Rd Coralville IA 52241	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-10-25	Richard T Klemesrud	rickklemesrud@gmail.com	CORALVILLE	IA	United States	Brian Woods	Sherry Woods	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Richard T Klemesrud	rickklemesrud@gmail.com	Myself / Owner	CORALVILLE	IA	United States	Brian Woods	Sherry Woods	Signed
1999	2024-01-25 16:57	Anonymous (not verified)	94.188.205.177	Nicholas Schaff	Limited Liability Company	6934 rolling ridge ct sw cedar rapids 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.	2024-01-25	Nicholas Schaff	schaff.lawncare@gmail.com	cedar rapids	linn	iowa	Brian Zeller	Cassie Schaff	Signed	(1) The employer does not elect the employers’ liability coverage.	Nicholas schaff	schaff.lawncare@gmail.com	Same person	cedar rapids	iowa	iowa	Brian zeller	cassie schaff	Signed
1158	2022-06-17 06:34	Anonymous (not verified)	97.125.255.177	Zach Ellis	Proprietorship	3013 Se Stoneridge St 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.	2022-06-17	Zachary Ellis	zach2865@gmail.com	Grimes	IA	United States	Brittany Klien	Kennedy Ellis	Signed	(1) The employer does not elect the employers’ liability coverage.	Zachary Ellis	zach2865@gmail.com	Myself	Grimes	Polk	Iowa	Brittany Klien	Kennedy Ellis	Signed
663	2021-10-04 09:45	Anonymous (not verified)	166.181.80.1	Matthew Winters	Proprietorship	9220 Summit Dr Johnston IA 50131	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-04	Matthew Winters	mattwinters55@gmail.com	Johnston	Polk	Iowa	Brittany Strub	Judy Sansom	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Winters	mattwinters55@gmail.com	Self	Johnston	Polk	Iowa	Brittany Strub	Judy Sansom	Signed
1580	2023-04-17 20:22	Anonymous (not verified)	94.188.205.167	Lance Van Der weerd	Limited Liability Company	909 S Adams Street Rock Rapids IA 51246	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Lance Van Der Weerd	enterprisesvdw@gmail.com	Rock Rapids	IA	United States	Brittany Van Der Weerd	Todd Mienerts	Signed	(1) The employer does not elect the employers’ liability coverage.	Lance Van Der Weerd	enterprisesvdw@gmail.com	Myself	Rock Rapids	Lyon	Iowa	Brittany Van Der Weerd	Todd Mienerts	Signed
1804	2023-08-16 18:22	Anonymous (not verified)	94.188.207.226	Zach Moyle Masonry	Limited Liability Company	7222 Great River 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.	2023-08-16	Zach Moyle	zmoylemasonry@gmail.com	Clermont	FAYETTE	FAYETTE	Brittney Loyd	Dave Moyle	Signed	(1) The employer does not elect the employers’ liability coverage.	Zach Moyle	zmoylemasonry@gmail.com	Self	Clermont	FAYETTE	FAYETTE	Brittney Loyd	Dave Moyle	Signed
199	2020-07-09 10:49	Anonymous (not verified)	167.142.98.40	Ryan Stott	Proprietorship	1513 Hawthorne Lane	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-09	Ryan Lynn Stott	rlstott@hotmail.com	Jefferson	Greene	Iowa	Brock Chisum	Brian Chisum	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Stott	rlstott@hotmail.com	self	Jefferson	Greene	Iowa	Brock Chisum	Brian Chisum	Signed
26	2020-01-04 17:23	Anonymous (not verified)	45.53.67.52	Gary De Jager	Limited Liability Company	417 florida Ave NW Orange City Iowa 51041	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-04	Gary Dean De Jager	mightyspear60@yahoo.com	Orange City	Souix	Iowa	Brody Dean De Jager	Tyler Ray De Jager	Signed	(1) The employer does not elect the employers’ liability coverage.	Gary Dean De Jager	mightyspear60@yahoo.com	owner	Orange City	souix	Iowa	Brody Dean De Jager	Tyler Ray De Jager	Signed
1834	2023-09-08 15:04	Anonymous (not verified)	94.188.205.177	Ryan Tucker	Proprietorship	19000 hwy 69	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-08	Ryan Tucker	rtlltucker@yahoo.com	Indianola	Warren	Iowa	Brooke Prior	Aly Brose	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Tucker	rtlltucker@yahoo.com	Officer	Indianola	Warren	Iowa	Brooke Prior	Aly Brose	Signed
1621	2023-05-01 15:53	Anonymous (not verified)	94.188.207.226	Hearing Health Care	Limited Liability Partnership	2519 S 16TH 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.	2023-05-01	Melissa Knoell	MELISSAKNOELL@YAHOO.COM	COUNCIL BLFS	IA	IA	Bruce Carol Johnk	Marcelyn Maureen Johnk	Signed	(1) The employer does not elect the employers’ liability coverage.	Melissa Knoell	melissaknoell@yahoo.com	self	Council Bluffs	Pottawattomi	IA	Bruce Carol Johnk	Marcelyn Maureen Johnk	Signed
630	2021-09-01 19:29	Anonymous (not verified)	97.125.133.79	Aaron J. Rosenbaum	Proprietorship	2005 Pine St, Granger, IA 50109	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-01	Aaron J. Rosenbaum	aabaum7@gmail.com	Granger	Dallas	Iowa	Bruce Klinkenberg	Trudy Rosenbaum	Signed	(1) The employer does not elect the employers’ liability coverage.	Aaron Rosenbaum	aabaum7@gmail.com	self	Granger	Dallas	Iowa	Bruce Klinkenberg	Trudy Rosenbaum	Signed
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
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
1149	2022-06-09 17:43	Anonymous (not verified)	174.235.192.238	Bryan Linares	Limited Liability Company	630 Hawthorne Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-09	Bryan Linares	bryan.linares7798@gmail.com	Crete	Saline	Nebraska	Bryan Linares	Chris Linares	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher Linares	chris5linares1995@gmail.com	Brother	Crete	Saline	Nebraska	Bryan Linares	Chris Linares	Signed
1356	2022-11-02 08:21	Anonymous (not verified)	174.215.249.84	Leaf home solutions	Proprietorship	1595 Georgetown Road, Hudson, OH 44236	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-02	Micheal Wills	mwills5304@gmail.com	Granger	Polk	IA	Bryanna Wills	Andrew Vannausdle	Signed	(1) The employer does not elect the employers’ liability coverage.	Bryanna Wills	bryannawills725@gmail.com	None	Granger	Polk	IA	Andrew Vannausdle	Micheal Wills	Signed
110	2020-04-06 14:13	Anonymous (not verified)	99.203.98.177	Stifel seasonal services	Limited Liability Company	935 4th street waukee	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-06	Dalton Stifel	daltonstifel@icloud.com	waukee	Dallas	IA	Bryant ternes	Tammy stifel	Signed	(1) The employer does not elect the employers’ liability coverage.	Dalton Stifel	daltonstifel@icloud.com	Owner	waukee	Dallas	IA	Bryant Ternes	Tammy Stifel	Signed
1034	2022-04-05 11:43	Anonymous (not verified)	75.162.133.214	Riftworks Wood Manufactory	Proprietorship	3807 Adams Ave, Des moines, Iowa 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-05	Bryan Siever	bryan@siever.us	Des Moines	IA	United States	Cakeb Payne	Tyler Anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Bryan siever	bryan@siever.us	Business owner	Des Moines	IA	United States	Caleb Payne	Tyler Anderson	Signed
1060	2022-04-19 15:08	Anonymous (not verified)	64.186.23.83	CORRECTIONVILLE GOLF CLUB, INC	Limited Liability Company	1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-19	ADAM KELLY	dslkraz@gmail.com	CORRECTIONVILLE	WOOD	IWOA	CANDACE	AMBER HANSEN	Signed	(1) The employer does not elect the employers’ liability coverage.	KATIE EDWARDS	kedwards@fnbcorrectionville.com	SEC/TREASURER	CORRECTIONVILLE	WOODBURY	IOWA	CANDACE JACOBSON	AMBER HANSEN	Signed
339	2020-12-15 15:23	Anonymous (not verified)	74.221.46.229	CORRECTIONVILLE GOLF CLUB INC	Limited Liability Company	1300 HACKBERRY STREET CORRECTIONVILLE IA 51016	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-12-15	KATIE EDWARDS	KEDWARDS@FNBCORRECTIONVILLE.COM	CORRECTIONVILLE	WOODBURY	IA	CANDACE JACOBSON	AMBER HANSEN	Signed	(1) The employer does not elect the employers’ liability coverage.	KIM MEBIUS	KMEBIUS@FNBCORRECTIONVILLE.COM	PRESIDENT	CORRECTIONVILLE	WOODBURY	IA	CANDACE JACOBSON	AMBER HANSEN	Signed
1059	2022-04-19 15:06	Anonymous (not verified)	64.186.23.83	CORRECTIONVILL GOLF CLUB, INC	Limited Liability Company	1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-19	NICK HEATH	dogboy3485@yahoo.com	CORRECTIONVILLE	WOODBURY	IOWA	CANDACE JACOBSON	AMBER HANSEN	Signed	(1) The employer does not elect the employers’ liability coverage.	KATIE EDWARDS	kedwards@fnbcorrectionville.com	SEC/TREASURER	CORRECTIONVILLE	WOODBURY	IOWA	CANDACE JACOBSON	AMBER HANSEN	Signed
390	2021-02-10 14:24	Anonymous (not verified)	173.24.190.134	King Excavation, LLC	Limited Liability Company	5343 410th St, Cylinder IA 50528	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-03	Aletha King	aletha1949@ncn.net	Cylinder	Palo Alto	Iowa	Candie Clark	Dave Walters	Signed	(1) The employer does not elect the employers’ liability coverage.	Aletha King	aletha1949@ncn.net	Member of LLC	Cylinder	Palo Alto	Iowa	Candie Clark	Dave Walters	Signed
391	2021-02-10 14:27	Anonymous (not verified)	173.24.190.134	King Excavation, LLC	Limited Liability Company	5343 410th St, Cylinder IA 50528	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-03	Beth King	aletha1949@ncn.net	Cylinder	Palo Alto	Iowa	Candie Clark	Dave Walters	Signed	(1) The employer does not elect the employers’ liability coverage.	Beth King	aletha1949@ncn.net	Member of LLC	Cylinder	Palo Alto	Iowa	Candie Clark	Dave Walters	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
794	2021-12-14 14:18	Anonymous (not verified)	65.144.174.26	iDesign	Limited Liability Company	805 15th St, Dallas Center, IA 50063	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-14	Michelle Wiedman	idesigninside@gmail.com	Dallas Center	Dallas	IA	Carl Sprague	Neal Bunn	Signed	(1) The employer does not elect the employers’ liability coverage.	Michelle Wiedman	idesigninside@gmail.com	Self	Dallas Center	Dallas	Iowa	Carl Sprague	Neal Bunn	Signed
1228	2022-07-26 10:06	Anonymous (not verified)	173.23.93.3	Gaytan Framing LLC	Limited Liability Company	2418 East 37th Court	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-26	Jose Gaytan	jose1988.jg8@gmail.com	Des Moines	Polk	United States	CARLA C. GAYTAN	Juan Franco	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Gaytan	jose1988.jg8@gmail.com	self	Des Moines	IA	United States	CARLA C. GAYTAN	Juan franco	Signed
1380	2022-11-26 07:41	Anonymous (not verified)	173.17.229.18	M&M Construction LLC	Limited Liability Company	32785 Homestead 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.	2022-11-23	Amparo Yamilet Menendez Gonzalez	menendez.amparo@yahoo.com	Granger	Dalles center	United States	Carla Diaz	Jesus Lopez	Signed	(1) The employer does not elect the employers’ liability coverage.	Gerardo Alvarado	bariel578@gmail.com	Employee	Perry	IA	United States	Carla Diaz	Jesus lopez	Signed
588	2021-07-27 19:59	Anonymous (not verified)	75.162.226.22	Andres Martinez	Limited Liability Company	3903 SW 3rd St. Des Moines, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-27	Andres Martinez	and.am12am@gmail.com	Des Moines	Polk	Iowa	Carla Martinez	Librado Martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Andres Martinez	and.am12am@gmail.com	Employer	Des Moines	Polk	Iowa	Carla Martinez	Librado Martinez	Signed
2057	2024-02-26 16:17	Anonymous (not verified)	94.188.207.228	Pedro Salazar Trejo	Proprietorship	1116 18th Ave SW 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.	2024-02-26	Pedro Salazar Trejo	pedrosalazart@icolud.com	Cedar rapids	Linn County	IA	Carlos Izaguirre	Omar Trejo	Signed	(1) The employer does not elect the employers’ liability coverage.	Martiniano Germán Maldonado	maldonadomartiniano675@gmail.com	Employee	Cedar rapids	Linn County	Iowa	Carlos Izaguirre	Omar Trejo	Signed
872	2022-01-30 18:54	Anonymous (not verified)	75.162.11.91	Iowa Carpentry Construction	Limited Liability Company	3000 University Ave #18105 West Des Moines,IA 50266	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-30	Carlos Velazquez	jlctrimcarpenter@gmail.com	Wes Des Moines	Polk	Iowa	Carlos Velazquez	Martha Marca	Signed	(1) The employer does not elect the employers’ liability coverage.	Iowa Carpentry Construcion	iowacarpentryconstruction@gmail.com	Worker	West Des Moines	Polk	Iowa	Carlos Velazquez	Martha Marca	Signed
233	2020-08-17 14:24	Anonymous (not verified)	165.225.0.98	Daniel L Knebel	Proprietorship	439 Carroll Blvd, Dunkerton, IA, 50626	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-17	Daniel L Knebel	knebeldan@gmail.com	Dunkerton	Black Hawk	Iowa	Carman M Knebel	Joseph E Knebel	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel L Knebel	knebeldan@gmail.com	Owner	Dunkerton	Black Hawk	Iowa	Carman M Knebel	Joseph E Knebel	Signed
488	2021-04-20 13:42	Anonymous (not verified)	69.63.16.2	STC Construction LLC	Limited Liability Company	329 Sycamore St, Riverside, IA 52327	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-20	Sean Crane	stc0241@gmail.com	Riverside	Washington	Iowa	Carol Glass	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Sean Crane	stc0241@gmail.com	Managing Member	Riverside	Washingon	Iowa	Carol Glass	Dyan Kriener	Signed
1302	2022-09-11 22:05	Anonymous (not verified)	174.198.65.241	Bruce g Sellner	Proprietorship	40998 597th ave new ulm mn 56073	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-11	Bruce g Sellner	bgsellner74@gmail.com	New ulm	Nicollet	Minnesota	Carol m aura	Steve l griebel	Signed	(1) The employer does not elect the employers’ liability coverage.	Bruce g Sellner	bgsellner74@gmail.com	Owner	New ulm	Nicollet	Mn	Carol m aura	Steve l griebel	Signed
1303	2022-09-11 22:05	Anonymous (not verified)	174.198.65.241	Bruce g Sellner	Proprietorship	40998 597th ave new ulm mn 56073	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-11	Bruce g Sellner	bgsellner74@gmail.com	New ulm	Nicollet	Minnesota	Carol m aura	Steve l griebel	Signed	(1) The employer does not elect the employers’ liability coverage.	Bruce g Sellner	bgsellner74@gmail.com	Owner	New ulm	Nicollet	Mn	Carol m aura	Steve l griebel	Signed
1304	2022-09-11 22:05	Anonymous (not verified)	174.198.65.241	Bruce g Sellner	Proprietorship	40998 597th ave new ulm mn 56073	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-11	Bruce g Sellner	bgsellner74@gmail.com	New ulm	Nicollet	Minnesota	Carol m aura	Steve l griebel	Signed	(1) The employer does not elect the employers’ liability coverage.	Bruce g Sellner	bgsellner74@gmail.com	Owner	New ulm	Nicollet	Mn	Carol m aura	Steve l griebel	Signed
491	2021-04-20 15:57	Anonymous (not verified)	199.102.210.217	mjm,inc	Proprietorship	32345 200th st dallas centert ia 50063	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-20	john paul wewrner	johnpwerner17@gmail.com	osage	michell	ia	carolyn lee werner	amanda lee johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	johnwerner	johnpwerner17@gmail.com	friend	osage	mithell	ia	carolyn lee werner	amanda lee johnson	Signed
14	2019-12-30 17:22	Anonymous (not verified)	173.20.51.69	Rotten Love LLC	Limited Liability Company	1101 Valentine Drive, Dubuque Iowa 52003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-01-01	john rettenmeier	jrettenmeier@gmail.com	dubuque	Dubuque	iowa	Carolyn Schmid	Joe Rettenmeier	Signed	(1) The employer does not elect the employers’ liability coverage.	Carolyn Schmid	jrettenmeier@gmail.com	owner	Dubuque	Dubuque	iowa	John Rettenmeier	John Rettenmeier	Signed
1712	2023-06-26 20:33	Anonymous (not verified)	94.188.205.167	Eastern Iowa Overhead Door	Proprietorship	120 N Eliza 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.	2023-06-26	Tim Chapin	easterniadoor@gmail.com	Maquoketa	IA	United States	Carri Lee Waack	Wendy Marie Zaruba	Signed	(1) The employer does not elect the employers’ liability coverage.	Tim Chapin	easterniadoor@gmail.com	Owner	Maquoketa	Jackson	United States	Carri Lee Waack	Wendy Marie Zaruba	Signed
1855	2023-09-27 12:56	Anonymous (not verified)	94.188.207.224	Lincoln Hotel Group	Limited Liability Company	9240 Andermatt Drive Suite 1	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-27	John Edward Klimpel	jklimpel@lincolnhotelgroup.com	Lincoln	Lancaster	NE	Carrie A. Fleck	Jill N. Korta	Signed	(1) The employer does not elect the employers’ liability coverage.	Brent Besch	brent.besch@marshmma.com	Client	Lincoln	Nebraska	NE	Carrie A Fleck	Jill N Korta	Signed
918	2022-02-16 14:23	Anonymous (not verified)	172.58.22.152	RICK MYSAK LLC	Limited Liability Company	2220 GREY WOLF, 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.	2022-02-16	RICK MYSAK	camysak@gmail.com	Hiawatha	LINN	IOWA	Carrie Mysak	RICK DeNEVE	Signed	(1) The employer does not elect the employers’ liability coverage.	RICK MYSAK	camysak@gmail.com	SELF	Hiawatha	LINN	IOWA	Carrie Mysak	RICK DeNEVE	Signed
266	2020-09-21 18:08	Anonymous (not verified)	174.126.94.77	Club Fantasy Inc.	Limited Liability Company	P.O. Box 5115 Sioux City Iowa 51102	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-21	Curtis A. Behr	cacbehr@aol.com	Sioux City	Woodbury	Iowa	Carter Vahle	Dawn Meyer	Signed	(1) The employer does not elect the employers’ liability coverage.	Curtis A. Behr	cacbehr@aol.com	Self	Sioux City	Woodbury	Iowa	Carter Vahle	Dawn Meyer	Signed
2044	2024-02-15 09:52	Anonymous (not verified)	94.188.205.168	Messenger Trucking LLC	Limited Liability Company	1869 255th 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.	2024-02-08	Timothy Duncan Messenger	tmessengertrucking@gmail.com	Fairfield	Jefferson	Iowa	Casey Messenger	Bud Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Timothy Duncan Messenger	tmessengertrucking@gmail.com	Self	Fairfield	Jefferson	Iowa	Casey Messenger	Bud Smith	Signed
1138	2022-06-01 15:01	Anonymous (not verified)	173.18.233.175	Roy Rohwedder	Proprietorship	296 24th Ave SW Cedar Rapids, IA 52404	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-01	Roy h Rohwedder	rohwedder.roy@yahoo.com	Cedar Rapids	linn	iowa	Cash Rohwedder	Brian Ashlock	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Ashlock	brian@tricounty-iowa.com	Genaral Manager	Cedar Rapids	Linn	IOWA	Branden Peters	Jenny Vaske	Signed
1604	2023-04-26 09:03	Anonymous (not verified)	94.188.207.225	LeafHome Solutions LLC	Limited Liability Company	3060 SE Grimes Boulevard 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.	2023-04-26	Braedyn Baylor	bbaylor66@gmail.com	West des moines	Polk	Iowa	Cassidy Tolle	Jeffrey Baylor	Signed	(1) The employer does not elect the employers’ liability coverage.	Braedyn Baylor	bbaylor66@gmail.com	Self	West Des Moines	Polk	Iowa	Julie Baylor	Brianna Stephens	Signed
58	2020-02-10 21:18	Anonymous (not verified)	75.162.11.63	Moni tile Services llc	Limited Liability Company	2207 E Walnut 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.	2020-02-01	Monica M Sandoval	Mjsandoval20@yahoo.com	Des Moines	Polk	United States	Cassie Ann bentz	James wesley harkert	Signed	(1) The employer does not elect the employers’ liability coverage.	Moni tile services llc	Mjsandoval20@yahoo.com	Self	Des Moines	Polk	Iowa	Cassie Ann bentz	James wesley harkert	Signed
748	2021-11-15 13:01	Anonymous (not verified)	174.243.83.168	NC contracting	Limited Liability Company	2212 Oakwood Rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-15	Nicholas Cheney	444nicholas@gmail.com	Ames	Iowa	Iowa	Cassie Cheney	Shawn Hay	Signed	(1) The employer does not elect the employers’ liability coverage.	Nicholas Cheney	444nicholas@gmail.com	Self	Ames	Story	Iowa	Cassie Cheney	Shawn Hay	Signed
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
1768	2023-07-29 11:10	Anonymous (not verified)	94.188.207.223	Makana Industries LLC	Limited Liability Company	1800 Grand Ave #352, 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.	2023-07-29	Matthew Akana	mandiremod515@gmail.com	West Des Moines	Polk	Iowa	Catherine Sobrado	James Fowler	Signed	(1) The employer does not elect the employers’ liability coverage.	Rocket Lawyer Corporate Services LLC	mandiremod515@gmail.com	Registered agent	Des Moines	Polk	Iowa	Catherine Sobrado	James Fowler	Signed
1929	2023-11-30 10:46	Anonymous (not verified)	94.188.207.225	White Masonry, Inc.	Proprietorship	15141 Bluff Trl., Carlisle, IA 50047	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-30	Jeff White	whitemasonry1979@hotmail.com	Carlisle	IA	IA	Cathleen Marie White	Sam Jeffrey White	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeffrey Dean White	WHITEMASONRY1979@HOTMAIL.COM	Self	CARLISLE	ia	ia	Cathleen Marie White	Sam Jeffrey White	Signed
343	2020-12-28 10:46	Anonymous (not verified)	173.18.204.82	Shelly Hildebrand	Proprietorship	424 E 44th St Pleasant Hill 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.	2020-12-28	Shelly Hildebrand	centraliowacleaningservice@mediacombb.net	Pleasant Hill	Polk	Iowa	Cathy Stevens	Bailey Hildebrand	Signed	(1) The employer does not elect the employers’ liability coverage.	Shelly Hildebrand	centraliowacleaningservice@mediacombb.net	Self	Pleasant Hill	Polk	Iowa	Cathy Stevens	Bailey Hildebrand	Signed
2075	2024-03-05 22:32	Anonymous (not verified)	94.188.207.225	Steve Roland Trucking LLC	Limited Liability Company	2141 Wadsley 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.	2024-03-05	Steve Roland	roland.farms@yahoo.com	Sac City	IA	United States	Caylee Hoffard	Kristen Wirtjers	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Roland	roland.farms@yahoo.com	Owner/Member	Sac City	IA	United States	Caylee Hoffard	Kristen Wirtjers	Signed
2076	2024-03-05 22:38	Anonymous (not verified)	94.188.207.229	Steve Roland Trucking LLC	Limited Liability Company	2141 Wadsley 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.	2024-03-05	Steve Roland	roland.farms@yahoo.com	Sac City	Sac	Iowa	Caylee Hoffard	Kristen Wirtjers	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Roland	roland.farms@yahoo.com	Owner/Member	Sac City	Sac	Iowa	Caylee Hoffard	Kristen Wirtjers	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
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
1974	2024-01-04 13:12	Anonymous (not verified)	94.188.205.167	Cro Outdoor Services, LLC	Limited Liability Company	1616 NW 78TH 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.	2023-12-20	Bojan Djukic	Croodsia@gmail.com	Clive	Iowa	United States	Cezar Villalobos	Maria Villalobos	Signed	(1) The employer does not elect the employers’ liability coverage.	Evetee Villalobos	e.villalobos91@gmail.com	s/o	Clive	IA	United States	Maria Villalobos	Cezar Villalobos	Signed
1108	2022-05-16 16:14	Anonymous (not verified)	4.4.30.34	David Sickels	Proprietorship	2221 Radcliffe Drive SW, Cedar Rapids, IA 52404	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-16	David Sickels	glsickels@gmail.com	Cedar Rapids	IA	United States	Chad Allen Taylor	Steven Thomas Dunn	Signed	(1) The employer does not elect the employers’ liability coverage.	David Allen Sickels	glsickels@gmail.com	self	Cedar Rapids	Linn	Iowa	Chad Allen Taylor	Steven Thomas Dunn	Signed
1940	2023-12-05 15:11	Anonymous (not verified)	94.188.207.227	David Sickels	Proprietorship	2221 Radcliffe drive s.w cedar rapids Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-05	David Sickels	davidasickels@gmail.com	Cedar rapids	Linn	Iowa	Chad Allen Taylor	Steven Thomas Dunn	Signed	(1) The employer does not elect the employers’ liability coverage.	David Allen Sickels	davidasickels@gmail.com	Self	Cedar Rapids	Linn	Iowa	Chad Allen Taylor	Steven Thomas Dunn	Signed
33	2020-01-09 15:57	Anonymous (not verified)	173.28.28.57	FALCON PRIDE PROPERTIES LLC	Limited Liability Company	1401 HWY 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.	2019-12-13	TODD THOMAS	todd@wimcoach.com	PARKERSBURG	BUTLER	IA	CHAD CAMPBELL	ROXANNE KOLDER	Signed	(1) The employer does not elect the employers’ liability coverage.	TODD THOMAS	todd@wimcoach.com	SELF	PARKERSBURG	BUTLER	IA	CHAD CAMPBELL	ROXANNE KOLDER	Signed
35	2020-01-13 13:23	Anonymous (not verified)	173.28.28.57	Milkhouse Market, LLC	Limited Liability Company	911 Parriott Street, Aplington IA 50604	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-12-30	MARY MEYER	cmins_re@mchsi.com	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	MARY MEYER	cmins_re@mchsi.com	Self	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
36	2020-01-15 13:26	Anonymous (not verified)	173.28.28.57	Shirley Pepples	Proprietorship	206 4th Street, Parkersburg, IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-14	Shirley Pepples	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Shirley Pepples	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
50	2020-02-03 14:55	Anonymous (not verified)	173.28.28.57	Silverleaf Capital, LLC	Limited Liability Company	1606 Palmer Court, 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.	2020-01-20	Silverleaf Capital, LLC	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Silverleaf Capital, LLC	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
51	2020-02-04 10:31	Anonymous (not verified)	173.28.28.57	Sister Style, LLC	Limited Liability Company	211 3rd Street, Parkersburg IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-23	Lisa Ellis	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Lisa Ellis	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
52	2020-02-04 10:35	Anonymous (not verified)	173.28.28.57	Sister Style, LLC	Limited Liability Company	211 3rd Street, Parkersburg IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-23	Amanda Jorgenson	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Amanda Jorgenson	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
54	2020-02-06 14:18	Anonymous (not verified)	173.28.28.57	Dale Hansman dba Klinkenborg Hansmann Law Office	Proprietorship	1201 Hwy 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.	2020-01-14	Dale Hansmann	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Dale Hansmann	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
129	2020-04-24 15:28	Anonymous (not verified)	173.28.28.57	Michael Jansen	Proprietorship	108 6th Street, Parkersburg, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-10	Michael G Jansen	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael G Jansen	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
148	2020-05-04 15:49	Anonymous (not verified)	173.28.28.57	LaRae Randall dba Wild Soul Photo	Proprietorship	19019 O Avenue, Grundy Center, IA 50638	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-27	LaRae Randall	cmins_re@mchsi.com	Grundy Center	Grundy	IA	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	LaRae Randall	cmins_re@mchsi.com	Self	Grundy Center	Grundy	IA	Chad Campbell	Roxanne Kolder	Signed
157	2020-05-14 15:11	Anonymous (not verified)	173.28.28.57	Brett Dix	Proprietorship	16696 245th Street, Aplington, IA 50604	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-30	Brett Dix	cmins_re@mchsi.com	Aplington	Butler	IA	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Brett Dix	cmins_re@mchsi.com	Self	Aplington	Butler	IA	Chad Campbell	Roxanne Kolder	Signed
159	2020-05-18 14:21	Anonymous (not verified)	173.28.28.57	Matthew Klahsen	Proprietorship	1103 Gray Street, Aplington IA 50604	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-12	Matthew Klahsen	cmins_re@mchsi.com	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Klahsen	cmins_re@mchsi.com	Self	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
160	2020-05-18 15:04	Anonymous (not verified)	173.28.28.57	Angela Scanlan	Proprietorship	26436 320th Street, Parkersburg IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-28	Angela Scanlan	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Angela Scanlan	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
170	2020-06-01 13:31	Anonymous (not verified)	173.28.28.57	Rachel Poppens	Proprietorship	910 Parriott Street, Aplington IA 50604	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-19	Rachel Poppens	cmins_re@mchsi.com	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Rachel Poppens	cmins_re@mchsi.com	Self	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
177	2020-06-08 11:00	Anonymous (not verified)	173.28.28.57	Lakeview Retreat Center, LLC	Limited Liability Company	17726 260th Street, Aplington IA 50604	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-23	Kendale Winkowitsch	cmins_re@mchsi.com	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Kendale Winkowitsch	cmins_re@mchsi.com	Self	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
185	2020-06-12 14:50	Anonymous (not verified)	173.28.28.57	Aaron & Eliesa Thomas	Partnership	706 3rd Avenue, 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.	2020-05-20	Aaron & Eliesa Thomas	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Aaron & Eliesa Thomas	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
215	2020-07-27 13:45	Anonymous (not verified)	173.28.28.57	Main Street Printing & Design, LLC	Limited Liability Company	706 3rd Avenue, 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.	2020-07-09	Aaron Thomas	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Aaron Thomas	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
216	2020-07-27 13:47	Anonymous (not verified)	173.28.28.57	Main Street Printing & Design, LLC	Limited Liability Company	706 3rd Avenue, 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.	2020-07-09	Eliesa Thomas	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Eliesa Thomas	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
227	2020-08-07 13:47	Anonymous (not verified)	173.28.28.57	Coffee Grounds, LLC dba Bev & Hennie's	Limited Liability Company	604 Hwy 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.	2020-07-28	Missy Schellhorn	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Missy Schellhorn	cmins_re@mchsi.com	Self	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
228	2020-08-07 13:49	Anonymous (not verified)	173.28.28.57	Coffee Grounds, LLC dba Bev & Hennie's	Limited Liability Company	604 Hwy 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.	2020-07-28	Kent Klooster	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Kent Klooster	cmins_re@mchsi.com	Self	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
236	2020-08-18 16:15	Anonymous (not verified)	173.28.28.57	Michael Ballhagen	Proprietorship	279 Pine Street, Allison IA 50602	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-07	Michael Ballhagen	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Ballhagen	cmins_re@mchsi.com	Self	Allison	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
307	2020-11-04 14:43	Anonymous (not verified)	50.82.130.211	ALL N DESIGNS, LLC	Limited Liability Company	601 Nicklaus Drive, 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.	2020-10-23	Aimee Allan	cmins_re@mchsi.com	Parkersburg	Butler	iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Aimee Allan	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
318	2020-11-16 15:06	Anonymous (not verified)	50.82.130.211	Boulder Woodworks, LLC	Limited Liability Company	3011 Boulder Drive, Cedar Falls IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-28	Eric Simmons	cmins_re@mchsi.com	Cedar Falls	Black Hawk	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Eric Simmons	cmins_re@mchsi.com	Self	Cedar Falls	Black Hawk	Iowa	Chad Campbell	Roxanne Kolder	Signed
361	2021-01-12 16:04	Anonymous (not verified)	50.82.130.211	Gregory Lievens	Partnership	503 N. Main Street, Allison IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-12	Gregory Lievens	cmins_re@mchsi.com	Allison	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Gregory Lievens	cmins_re@mchsi.com	Self	Allison	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
383	2021-02-03 15:05	Anonymous (not verified)	50.82.130.211	David Kuehner	Proprietorship	P.O. Box 158, Allison IA 50602	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-08	David Kuehner	cmins_re@mchsi.com	Allison	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	David Kuehner	cmins_re@mchsi.com	Self	Allison	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
454	2021-03-26 09:46	Anonymous (not verified)	50.82.130.211	Jason Thoren	Proprietorship	104 1st Street NW, Tripoli, IA 50676	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-04	Jason Thoren	cmins_re@mchsi.com	Tripoli	Bremer	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Thoren	cmins_re@mchsi.com	Self	Tripoli	Bremer	Iowa	Chad Campbell	Roxanne Kolder	Signed
503	2021-05-05 11:27	Anonymous (not verified)	50.82.130.211	Davonius Reed	Limited Liability Company	1913 Upton Avenue, Waterloo IA 50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-01	Davonius Reed	cmins_re@mchsi.com	Waterloo	Black Hawk	IA	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Davonius Reed	cmins_re@mchsi.com	Self	Waterloo	Black Hawk	IA	Chad Campbell	Roxanne Kolder	Signed
520	2021-05-17 10:32	Anonymous (not verified)	50.82.130.211	Madison Oldenburger	Proprietorship	809 3rd Avenue, Parkersburg, IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-06	Madison Oldenburger	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Madison Oldenburger	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
525	2021-05-18 09:42	Anonymous (not verified)	50.82.130.211	Adrian Bernard	Proprietorship	803 Russell Circle, Parkersburg IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-07	Adrian Bernard	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Adrian Bernard	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Chad Campbell	Signed
632	2021-09-07 13:42	Anonymous (not verified)	50.82.130.211	Thomas Mann	Proprietorship	401 Miners Street, Parkersburg, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-09	Thomas Mann	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Thomas Mann	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
706	2021-11-02 11:45	Anonymous (not verified)	50.82.130.211	Kierstyn Anest	Proprietorship	1200 Parriott Street, Aplington IA 50604	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-25	Kierstyn Anest	cmins_re@mchsi.com	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Kerstyn Anest	cmins_re@mchsi.com	Self	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
847	2022-01-20 13:54	Anonymous (not verified)	50.82.130.211	Albatross Capital, LLC	Limited Liability Company	28003 290th Street, Parkersburg IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-22	Jesse Nitcher	cmins_re@mchsi.com	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Jesse Nitcher	cmins_re@mchsi.com	Member of LLC	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
848	2022-01-20 13:56	Anonymous (not verified)	50.82.130.211	Albatross Capital, LLC	Limited Liability Company	28003 290th St., Parkersburg IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-22	Chris Buseman	cmins_re@mchsi.com	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Chris Buseman	cmins_re@mchsi.com	Member of LLC	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed
849	2022-01-20 13:58	Anonymous (not verified)	50.82.130.211	Albatross Capital, LLC	Limited Liability Company	28003 290th St., Parkersburg IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-22	Brandon Huisman	cmins_re@mchsi.com	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandon Huisman	cmins_re@mchsi.com	Member of LLC	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed
850	2022-01-20 14:03	Anonymous (not verified)	50.82.130.211	Albatross Capital, LLC	Limited Liability Company	28003 290th St., Parkersburg IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-22	Justin Mehmen	cmins_re@mchsi.com	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Mehmen	cmins_re@mchsi.com	Member of LLC	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed
851	2022-01-20 14:10	Anonymous (not verified)	50.82.130.211	Albatross Capital, LLC	Limited Liability Company	28003 290th St., Parkersburg IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-22	Justin Mehmen	cmins_re@mchsi.com	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Mehmen	cmins_re@mchsi.com	Member of LLC	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed
995	2022-03-22 14:40	Anonymous (not verified)	50.82.130.211	Pietig Construction, LLC	Limited Liability Company	302 Brookside Dr, 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.	2022-03-09	Joel Pietig	cmins_re@mchsi.com	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Joel Pietig	cmins_re@mchsi.com	Owner/Self	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	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
954	2022-03-08 11:07	Anonymous (not verified)	174.192.138.191	Duwa Waterproofing	Limited Liability Company	729 Deer View Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-08	Stacy Duwa	duwawaterproofing@gmail.com	Tiffin	Johnson	Iowa	Chad Cooper	Curtis Sexton	Signed	(1) The employer does not elect the employers’ liability coverage.	Stacy Duwa	duwawaterproofing@gmail.com	President	Tiffin	Johnson	Iowa	Chad Cooper	Curtis Sexton	Signed
2056	2024-02-24 08:17	Anonymous (not verified)	94.188.207.230	C&C Property LLC	Limited Liability Partnership	PO Box 418	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-24	Joshua Darwin Wessel	wesselclublambs@gmail.com	Kiron	Crawford	IA	Chad D Foust	Chad A Tweeten	Signed	(1) The employer does not elect the employers’ liability coverage.	Chad Tweeten	tweeten@hotmail.com	Barn Manager 1099 employee	Eagle grove	Wright	Iowa	Chad Tweeten	Chad Foust	Signed
882	2022-02-02 11:09	Anonymous (not verified)	67.55.205.135	Tree & Forestry Equipment	Partnership	201 Deer Haven St., Polk City, IA 50226	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-02	Jennifer Hicks	jennifer@treeandforestry.com	Gowrie	Webster	Iowa	Chad Hicks	Caden Konecne	Signed	(1) The employer does not elect the employers’ liability coverage.	Jennifer Hicks	jennifer@treeandforestry.com	self	Gowrie	Webster	Iowa	Chad Hicks	Caden Konecne	Signed
124	2020-04-16 12:07	Anonymous (not verified)	96.3.180.122	Gold Rush, LLC	Limited Liability Company	1395 130TH ST	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-16	Jay Christopher Morrow	jcmorrow2@hotmail.com	WAYLAND	Henry	IAUS	chad mitchell	Jonathan Mitchell	Signed	(1) The employer does not elect the employers’ liability coverage.	Gold Rush, LLC	jcmorrow2@gmail.com	Self	WAYLAND	Henry	IAUS	chad mitchell	Jonathan Mitchell	Signed
1572	2023-04-13 11:12	Anonymous (not verified)	94.188.205.167	CK Trucking	Proprietorship	24497 Hayes Street, Pleasantville, Iowa 50225	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-13	Craig Kooyman	dmsstumpguy@yahoo.com	Pleasantville	IA	IA	Chad Randleman	James Jordan	Signed	(1) The employer does not elect the employers’ liability coverage.	Craig Kooyman	dmsstumpguy@yahoo.com	Owner	Pleasantville	Warren	IA	Chad Randleman	James Jordan	Signed
785	2021-12-09 09:15	Anonymous (not verified)	174.198.75.71	Daniel Vega camacho	Proprietorship	2415 river ,meadows drive Des Moines Iowa 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-09	Daniel Vega camacho	dvega50265@gmail.com	Des Moines	Polk	Iowa	Chad Smith	Adam Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Vega camacho	dvega50265@gmail.com	Self	Des Moines	Polk	Iowa	Chad Smith	Adam Smith	Signed
1134	2022-05-31 09:08	Anonymous (not verified)	65.125.92.130	EAC Multi-Services, Inc,	Proprietorship	6224 Forest Ave. Des Moines, IA 50311	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-31	Alan E Enamordo	enriqueecalowcare@gmail.com	Des Moines	Polk	Iowa	Chad Smith	Adam Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Alan E Enamordo	enriqueecalowcare@gmail.com	self	Des Moines	Polk	IA	Chad Smith	Adam Smith	Signed
1171	2022-06-24 09:40	Anonymous (not verified)	65.125.92.130	Vega's Pro Painting, LLC	Limited Liability Company	2415 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.	2022-06-24	Daniel Vega Camacho	dvega50265@gmail.com	Des Moines	Polk	IA	Chad Smith	Adam Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Vega Camacho	dvega50265@gmail.com	Self	Des Moines	Polk	IA	Chad Smith	Adam Smith	Signed
624	2021-08-30 15:53	Anonymous (not verified)	174.253.66.113	Leaf Home Solutions LLC	Limited Liability Company	1595 Georgetown Rd.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-30	Chad York	Cyork027@gmail.com	Davenport	Scott	Iowa	Chad York	Adam Coleman	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Coleman	ARColeman@leafhome.com	Recruiter	Hudson	Summit	Ohio	Chad York	Adam Coleman	Signed
1612	2023-04-27 10:37	Anonymous (not verified)	94.188.207.223	Grind Works LLC	Proprietorship	26416 289th place Unit H Adel IA 50003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-27	Adam Samuelson	Hello@grindworksia.com	Adel	Dallas	Iowa	Chandler Clark	Adam Samuelson	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Samuelson	Hello@Grindowrksia.com	N/A	Adel	Dallas	Iowa	Adam Samuelson	Chandler Clark	Signed
1895	2023-11-03 12:21	Anonymous (not verified)	94.188.207.227	Oxbo LLC	Limited Liability Company	2528 Evergreen Ave. Red Oak, IA 51566	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-03	Mettra Sperling	sperlingrose66@gmail.com	Red Oak	Montgomery	IA	Chantal Sperling	Derek Penry	Signed	(1) The employer does not elect the employers’ liability coverage.	Mettra Sperling	sperlingrose66@gmail.com	Self	Red Oak	Montgomery	IA	Chantal Sperling	Derek Penry	Signed
1772	2023-08-01 15:09	Anonymous (not verified)	94.188.205.168	MHI Services	Proprietorship	613 Damon St Council Bluffs, IA 51503	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-01	Lisa Mitchell	lmitchell939@gmail.com	Council Bluffs	Pottawattamie	Iowa	Charles Meckna	Christopher Young	Signed	(1) The employer does not elect the employers’ liability coverage.	LIsa MItchellj	lmitchell939@gmail.com	Self	Council Bluffs	Pottawattamie	Iowa	Charles Meckna	Christopher Young	Signed
1686	2023-06-12 07:45	Anonymous (not verified)	94.188.207.229	Robert Burman	Proprietorship	400 Lindale Dr 119 Marion, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-11	Robert Burman	robertburman791@gmail.com	Marion	Linn	Iowa	Charles Wood	Jordan Nisiewicz	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Charles Wood	Jordan loyd	Signed
1794	2023-08-10 14:56	Anonymous (not verified)	94.188.205.169	Alex Kiler	Proprietorship	10511 Main Road, La Porte City, IA 50651, 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.	2023-08-10	Alex Kiler	alexkiler12622@gmail.com	La Porte City, IA	Black Hawk County	Iowa	Charles Woods	Steve Geisler	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Charles Wood	Steven Geisler	Signed
1148	2022-06-08 11:41	Anonymous (not verified)	70.96.153.153	Brody Willet LLC	Limited Liability Company	244 #rd Ave N, Alburnett, IA 52202	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-08	Brody Willet	brody@optionsexteriors.com	Alburnett	Linn County	Iowa	Charlotte Rasmussen	Austin Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Brody Willet	brody@optionsexteriors.com	Owner	Alburnett	Linn County	Iowa	Charlotte Rasmussen	Austin Miller	Signed
1152	2022-06-13 13:05	Anonymous (not verified)	70.96.153.153	Tyler Ankney	Proprietorship	1250 A 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.	2022-06-13	Tyler Ankney	tyler.a@optionsexteriors.com	Marion	Linn County	Iowa	Charlotte Rasmussen	Austin Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Tyler Ankney	tyler.a@optionsexteriors.com	Owner	Marion	Linn County	Iowa	Charlotte Rasmussen	Austin Miller	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
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
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
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
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
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
1963	2023-12-18 14:45	Anonymous (not verified)	94.188.207.227	Elite Excavation Services	Limited Liability Company	13335 Amber Rd X44 Anamosa Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-18	Dalton Starn	eliteexcavationservices97@gmail.com	Anamosa	Jones	Iowa	Chase miller	Nathan Decker	Signed	(1) The employer does not elect the employers’ liability coverage.	Dalton Starn	eliteexcavationservices97@gmail.com	Owner	Anamosa	Jones	Iowa	Chase miller	Nathan decker	Signed
650	2021-09-22 20:46	Anonymous (not verified)	174.198.68.116	Freedom field services	Limited Liability Company	6285 n 67 ave w baxter iowa 50028	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-22	joseph robert cunningham jr	joecunningham1966@protonmail.com	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed	(1) The employer does not elect the employers’ liability coverage.	joseph robert cunningham jr	joecunningham1966@protonmail.com	owner	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed
651	2021-09-22 21:05	Anonymous (not verified)	174.198.68.116	Freedom field services LLC	Limited Liability Company	6285 n 67 ave w. BAXTER IOWA 50028	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-22	joseph robert cunningham jr	joecunningham1966@protonmail.com	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed	(1) The employer does not elect the employers’ liability coverage.	joseph robert cunningham jr	joecunningham1966@protonmail.com	owner	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed
595	2021-08-03 13:53	Anonymous (not verified)	174.248.224.252	Joseph r cunningham dba freedom field services	Proprietorship	6285 n 67th ave w Baxter iowa 50028	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-03	Joseph r Cunningham jr.	joecunningham1966@protonmail.com	Baxter	Jasper	Iowa	Chelsey Cunningham	Chris Cort	Signed	(1) The employer does not elect the employers’ liability coverage.	Joseph r cunningham jr	joecunningham1966@protonmail.com	Me	Baxter	Jasper	Iowa	Chelsey cunningham	Chris cort	Signed

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