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:
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
2024	2024-02-06 20:31	Anonymous (not verified)	94.188.207.223	BTS Custom Floors	Proprietorship	22 wenwood cir	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-06	Brandon Clay	Brandon.btscustomfloors@gmail.com	Council Bluffs	Iowa	United States	Darin Thompson	Amber Swanson	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandon Clay	Brandon.btscustomfloors@gmail.com	I am them	Council Bluffs	Iowa	United States	Amber Swanson	Darin Thompson	Signed
1398	2022-12-21 22:02	Anonymous (not verified)	24.149.20.131	B's Lawn Care	Limited Liability Company	1118 Rainbow Drive, Cedar Falls, Iowa 50613, 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.	2022-12-21	Brandon Ballenger	lawncare.bee@gmail.com	Cedar Falls	Iowa	United States	Katie Ballenger	Tyler Ballenger	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandon Ballenger	lawncare.bee@gmail.com	Owner/Operator	Cedar Falls	Iowa	United States	Katie Ballenger	Tyler Ballenger	Signed
408	2021-02-18 10:51	Anonymous (not verified)	165.225.61.119	Brandon Anderson Painting	Proprietorship	608 30th St Rock Island, IL 61201	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-21	Brandon Anderson	banderson792@gmail.com	Rock Island	Rock Island	IL	Seth Rowland	Jay Romeo	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandon Anderson	banderson792@gmail.com	Self	Rock Island	Rock Island	IL	Seth Rowland	Jay Romeo	Signed
502	2021-05-04 12:56	Anonymous (not verified)	75.89.78.95	HENNICK TREE SERVICE LLC	Limited Liability Company	1852 MAINE RIDGE ROAD, CENTRAL CITY, IA 52214	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-05-04	BRANDON ALAN HENNICK	hennicktreeservice@gmail.com	CENTRAL CITY	LINN	IOWA	KATHY RUTH WOOD	ROBBIE WILLIAM WILLIS	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Brandon Hennick	hennicktreeservice@gmail.com	OWNER	CENTRAL CITY	IA	United States	KATHY RUTH WOOD	ROBBIE WILLIAM WILLIS	Signed
289	2020-10-23 14:42	Anonymous (not verified)	65.103.82.36	Go Green Lawn and Tree	Proprietorship	2911 N Harrison st Davenport IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-23	Brandon	gogreenlawnandtree@yahoo.com	davenport	scott	iowa	Kayla Artioli	Eric Johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	brandon gordon	gogreenlawnandtree@yahoo.com	self	davenport	scott	ia	kayla	eric	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
99	2020-03-23 16:47	Anonymous (not verified)	216.96.116.78	B’s Sweet Treats	Proprietorship	21484 196th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-23	Brandi Wehr	brndwehr54@hotmail.com	Sigourney	Keokuk	IA	Erik Wehr	Brenda Workman	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandi Wehr	brndwrhr54@hotmail.com	Self	Sigourney	Keokuk	IA	Brenda Workman	Erik Wehr	Signed
102	2020-03-25 11:23	Anonymous (not verified)	206.72.14.249	Brandi Wehr	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.	2020-03-25	Brandi Jo Wehr	brndwehr54@hotmail.com	Sigourney	Keokuk	Iowa	Amber Kephart	Mary Beth Knipfer	Signed	(1) The employer does not elect the employers’ liability coverage.	Chelsea Voss	chelsea@grimmrealestate.com	Agent	North English	Iowa	Iowa	Amber Kephart	Mary Beth Knipfer	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
1605	2023-04-26 09:48	Anonymous (not verified)	94.188.207.229	Double Barrell Construction	Proprietorship	1237 S 52nd St, #804, 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.	2023-04-26	Braedyn Baylor	bbaylor66@gmail.com	West Des Moines	Polk	IA	Peggy Toft	Rick Thompson	Signed	(1) The employer does not elect the employers’ liability coverage.	Braedyn Baylor	bbaylor66@gmail.com	Owner	West Des Moines	Polk	IA	Peggy Toft	Rick Thompson	Signed
1730	2023-07-09 23:39	Anonymous (not verified)	94.188.207.225	Steffens Constuction	Proprietorship	68222 Lansing Road, Wiota, IA 50274	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-07	Bradyn Richard Steffens	steffens4211@gmail.com	Wiota	Cass	Iowa	Katrina Sonntag	Chris Obrien	Signed	(1) The employer does not elect the employers’ liability coverage.	Audra Kelley Steffens	steffens4211@gmail.com	wife	Wiota	Cass	Iowa	Katrina Sonntag	Chris Obrien	Signed
1779	2023-08-03 15:40	Anonymous (not verified)	94.188.207.224	Action Garage Builders	Limited Liability Company	1635 Kerry Lane, Jesup, IA 50648	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-03	Brady Huls	brady.cve@gmail.com	Cedar Falls	Black Hawk	Iowa	Tyler Reynolds	Joshua Carder	Signed	(1) The employer does not elect the employers’ liability coverage.	Troy Even	actiongaragebuilders@gmail.com	Owner	Jesup	Buchanan	Iowa	Tyler Reynolds	Joshua Carder	Signed
1223	2022-07-22 15:14	Anonymous (not verified)	167.142.255.81	HomeOwner's Helper LLC	Limited Liability Company	111 4th Ave, Underwood, IA 51576	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-22	Bradley W Syndergaard	mrslouie8@yahoo.com	UNDERWOOD	Iowa	United States	Stacy L Louison	Brent C Louison	Signed	(1) The employer does not elect the employers’ liability coverage.	Bradley W Syndergaard	mrslouie8@yahoo.com	Self	UNDERWOOD	Iowa	United States	Stacy L Louison	Brent C Louison	Signed
944	2022-03-03 13:54	Anonymous (not verified)	192.95.125.191	B&R Enterprises LLC	Limited Liability Company	2850 73rd St., Newhall, IA 52315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-02-17	Bradley Rick	ashlyn@3riversins.net	Newhall	Benton	Iowa	Ashlyn Christianson	Angie McFarland	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Ronald Jarrett	brsirenguys@gmail.com	LLC Member	Newhall	Benton	Iowa	Ashlyn Christianson	Angie McFarland	Signed
1636	2023-05-10 07:31	Anonymous (not verified)	94.188.205.167	Brad Bower Drywall LLC	Limited Liability Company	209 Northridge 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.	2023-05-10	Bradley Bower	bbower74@gmail.com	West Branch	Cedar	Iowa	Kirk Strunk	Chris Hay	Signed	(1) The employer does not elect the employers’ liability coverage.	Brad Bower	bbower74@gmail.com	Self	West Branch	Cedar	Iowa	Kirk Strunk	Chris Hay	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
1721	2023-07-06 08:19	Anonymous (not verified)	94.188.207.228	Bradford Alexander Carr	Proprietorship	3349 Southgate Ct SW Ste 101	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Bradford Alexander Carr	alex.carr@thrivent.com	Coralville	Johnson	Iowa	Gaylon Heetland	David King	Signed	(1) The employer does not elect the employers’ liability coverage.	Bradford Alexander Carr	alex.carr@thrivent.com	Self	Coralville	Johnson	Iowa	Gaylon Heetland	David King	Signed
832	2022-01-12 17:23	Anonymous (not verified)	67.212.111.166	Cory's Painting LLC	Limited Liability Company	Po Box 1161 Cedar Falls, Iowa 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-13	Braden L Gray	grayb2014@gmail.com	Cedar Falls	Black Hawk County	Iowa	Kari Houle	Darren Dean Fanning	Signed	(1) The employer does not elect the employers’ liability coverage.	Cory Allen Koger	coryspainting@gmail.com	Self	Cedar Falls	Black Hawk County	Iowa	Kari Houle	Darren Dean Fanning	Signed
1354	2022-11-01 05:31	Anonymous (not verified)	75.162.229.216	Brad Sommers Construction, LLC.	Limited Liability Company	23653 N Ave, Dallas Center, Iowa 50063	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-31	Brad Sommers	Bsconst1@gmail.com	Dallas Center	Dallas	Iowa	Ben Sommers	Keith Winey	Signed	(1) The employer does not elect the employers’ liability coverage.	Brad Sommers	Bsconst1@gmail.com	owner	Dallas Center	Dallas	Iowa	Ben Sommers	Keith Winey	Signed
1116	2022-05-17 21:41	Anonymous (not verified)	75.162.182.172	Hinds Metal Designs LLC	Limited Liability Company	11409 Dakota St, Norwalk, IA 50211	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-18	Brad Hinds	bahinds@msn.com	Norwalk	Iowa	Iowa	Trevor Masten	Travis Masten	Signed	(1) The employer does not elect the employers’ liability coverage.	Carlene Hinds	carlene4082@msn.com	Self	Norwalk	Iowa	Iowa	Trevor Masten	Travis Masten	Signed
471	2021-04-13 10:35	Anonymous (not verified)	65.103.82.36	River City Floors	Proprietorship	2114 N Zenith Ave Davenport IA 52804	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-30	Brad Ernest Dahl	na@noemail.com	Davenport	Scott	IA	Dawn T	Ben S	Signed	(1) The employer does not elect the employers’ liability coverage.	Brad Dahl	na@noemail.com	Owner	Davenport	Scott	IA	Dawn T	Ben S	Signed
431	2021-03-10 14:41	Anonymous (not verified)	66.188.136.150	Brad Donovan	Proprietorship	1105 N 5th. Springfield, IL 62702	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-10	Brad Donovan	braddonovan40@gmail.com	Springfield	Sangamon	IL	Russell Masartis	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Brad Donovan	braddonovan40@gmail.com	Same	Springfield	Sangamon	IL	Russell Masartis	Shuree Behr	Signed
1262	2022-08-16 12:52	Anonymous (not verified)	74.137.151.70	Golds Custom Grading LLC	Limited Liability Company	Po Box 114 Spencer, IA 51301	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-16	Brad Carlson	brad_carlson@gmail.com	Spencer	Clay	Iowa	Thomas Dunn	Nancy Cassa	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Thomas Dunn	TDUNN@THOMASBRADLEYINSURANCE.COM	Agent	Madison	Dane	Wisconsin	Nancy Cassa	Brad Carlson	Signed
1077	2022-04-28 13:16	Anonymous (not verified)	149.20.212.228	Van Ginkel Farms LLC	Limited Liability Company	2745 Chestnut Ave Inwood, IA 51240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-14	Bonnie VanGinkel	bonnievanginkel@gmail.com	Inwood	Lyon	Iowa	Jesse Niemeyer	Jaslyn VanOtterloo	Signed	(1) The employer does not elect the employers’ liability coverage.	James VanGinkel	bonnievanginkel@gmail.com	owner	Inwood	Lyon	Iowa	Jesse Niemeyer	Jaslyn VanOtterloo	Signed
1029	2022-04-04 12:46	Anonymous (not verified)	174.215.242.124	Bonnie Seely	Proprietorship	43 rainbow court se Cedar Rapids Iowa 52403	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-04	Bonnie Elizabeth seely	bseely4@gmail.com	Cedar Rapids	Linn	Iowa	Mikaela Seely	Noah seely	Signed	(1) The employer does not elect the employers’ liability coverage.	Bonnie Seely	bseely4@gmail.com	Self	Cedar Rapids	IA	United States	Mikaela Seely	Noah Seely	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
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
759	2021-11-19 18:54	Anonymous (not verified)	173.23.148.83	EFP Construction	Limited Liability Company	1825 East Grand Ave Des Moines, Iowa 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-19	Bobby Perry	efpconstruction21@gmail.com	Des Moines	Polk	Iowa	Tanya Perry	Megan McIlhon	Signed	(1) The employer does not elect the employers’ liability coverage.	Bobby Perry	efpconstruction21@gmail.com	Self	Des Moines	Polk	Iowa	Tanya Perry	Megan McIlhon	Signed
604	2021-08-14 11:18	Anonymous (not verified)	69.54.119.134	Robert Curry	Limited Liability Company	10759 S 96th Ave W Prairie City IA 50228	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-14	Bob Curry	Gardengal4205@gmail.com	Prairie City	IA	United States	Megan Irwin	Rob Irwin	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Curry	Gardengal4205@gmail.com	Self	Prairie City	IA	United States	Megan Irwin	Rob Irwin	Signed
1975	2024-01-04 15:42	Anonymous (not verified)	94.188.207.229	Blake S. Judisch Masonry LLC	Limited Liability Company	510 South Fulton St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-04	Blake Judisch	blakejudisch@gmail.com	Shell rock	Butler	IA	Kali Judisch	Terri Thomsen	Signed	(1) The employer does not elect the employers’ liability coverage.	Blake Judisch	blalejudisch@gmail.com	Owner	Shell rock	Butler	IA	Kali Judisch	Terri Thomsen	Signed
1357	2022-11-03 15:06	Anonymous (not verified)	66.129.196.99	Blake Carson	Limited Liability Company	1550 plainview rd ely, IA 52227	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-21	Blake Dennis Carson	Blake@carsondesignsco.com	Ely	Linn	iowa	Dennis Carson	Jordan Mellinger	Signed	(1) The employer does not elect the employers’ liability coverage.	Blake Carson	Blake@carsondesignsco.com	member/Owner	Ely	linn	iowa	Dennis Carson	Jordan Mellinger	Signed
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
2168	2024-04-22 08:18	Anonymous (not verified)	94.188.207.228	Mattson's Floor Covering	Proprietorship	2073 Sandy 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.	2024-04-22	Blaine Linn Mattson	tmatzan99@yahoo.com	Oquawka	Henderson	Illinois	Cheryl Ross	Larry Rheinschmidt	Signed	(1) The employer does not elect the employers’ liability coverage.	Blaine Mattson	tmatzan22@yahoo.com	owner	Oquawka	Henderson	Illinois	Cheryl Ross	Larry Rheinschmidt	Signed
2176	2024-04-24 11:12	Anonymous (not verified)	94.188.205.176	Schutters Pest Control Inc.	Limited Liability Company	109 2nd Ave, Suite #2, Carbon Cliff,IL 61239	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-04	Billy Y Schutters	schutterspestcontrol@gmail.com	Bettendorf	Iowa	United States	Aidan Sammon	Kalissa Malin	Signed	(1) The employer does not elect the employers’ liability coverage.	Billy Y Schutters	schutterspestcontrol@gmail.com	Same Person	Carbon Cliff	Rock Island	Illinois	Aidan Sammon	Kalissa Malin	Signed
1352	2022-10-31 19:35	Anonymous (not verified)	173.17.8.56	Hutch's Parking Lot Sweeping INC	Limited Liability Company	5235 JENNIFER 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.	2022-10-31	Bill HUTCHINSON	btnwhutch@aol.com	PLEASANT HILL	Iowa	United States	TRACY HUTCHINSON	NIC HUTCHINSON	Signed	(1) The employer does not elect the employers’ liability coverage.	Bill HUTCHINSON	btnwhutch@aol.com	SELF	PLEASANT HILL	Iowa	United States	TRACY HUTCHINSON	NIC HUTCHINSON	Signed
1299	2022-09-07 14:55	Anonymous (not verified)	167.142.60.66	Harleen Trenching	Proprietorship	2066 X Ave, Madrid Iowa 50156	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-07	Bill Harleen	sandyharleen@hotmail.com	Madrid	Boone	Iowa	Thomas H Andersen	Dustin T Andersen	Signed	(1) The employer does not elect the employers’ liability coverage.	Bill Harleen	Harleentrenching@hotmail.com	Self	Madrid	Boone	Iowa	Thomas H Andersen	Dustin T Andersen	Signed
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
997	2022-03-23 06:15	Anonymous (not verified)	167.142.233.235	Betsy Harms Agency LLC	Limited Liability Company	101 Sherman Ave, Ackley, IA 50601	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-23	Betsy Harms	bharms@phillipsstafford.com	Ackley	Franklin	IA	Levi Harms	Patricia Harms	Signed	(1) The employer does not elect the employers’ liability coverage.	Betsy Harms	bharms@phillipsstafford.com	Self	Ackley	Franklin	IA	Levi Harms	Patricia Harms	Signed
169	2020-05-28 11:31	Anonymous (not verified)	173.31.147.225	RECYCLED SPIRITS LLC	Limited Liability Company	43 ANN ST MILFORD IA 51351	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-28	BETH LAMB	BLAMB@SPENCERSCHOOLS.ORG	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	BETH LAMB	BLAMB@SPENCERSCHOOLS.ORG	SELF	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	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
682	2021-10-19 16:15	Anonymous (not verified)	65.144.174.26	BBR Tile and Professional Installation LLC	Proprietorship	903 School Ave Norwalk, IA 50211	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-19	Bertin Baltazar	baltarey2009@gmail.com	Norwalk	Warren	Iowa	Enedelia Bonilla	Fernando Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Bertin Baltazar	baltarey2009@gmail.com	Owner	Norwalk	Warren	Iowa	Enedelia Bonilla	Fernando Garcia	Signed
1430	2023-01-25 14:50	Anonymous (not verified)	104.222.82.50	Pille Ceramic Tile	Proprietorship	17645 Guthrie Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-25	Bernie Pille	blpille@yahoo.com	Maple River	Carroll	IA	Lisa Pille	None	Signed	(1) The employer does not elect the employers’ liability coverage.	Bernie Pille	blpille@yahoo.com	Self	Maple River	Carroll	IA	Lisa Pille	Cameron Pille	Signed
551	2021-06-29 09:18	Anonymous (not verified)	72.168.160.90	BERNARD WATERBECK	Limited Liability Company	1353 280TH STREET, GARWIN, IOWA 50632	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-06-29	BERNARD WATERBECK	garwinacres2012@hotmail.com	GARWIN	TAMA	IOWA	DEAN KELLER	CESAR MARROQUIN	Signed	(1) The employer does not elect the employers’ liability coverage.	BERNARD WATERBECK	garwinacres2012@hotmail.com	SAME PERSON	GARWIN	TAMA	IOWA	DEAN KELLER	CESAR MARROQUIN	Signed
212	2020-07-20 16:43	Anonymous (not verified)	97.64.164.30	Bernard L. Gradoville D.D.S.	Proprietorship	2800 Ingersoll 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.	2020-07-20	Bernard Gradoville	bgradoville@ingersollfamilydentistry.com	Des Moines	IA	United States	Tricia Wilson	Jack Gradoville	Signed	(1) The employer does not elect the employers’ liability coverage.	Bernard Gradoville	bgradoville@ingersollfamilydentistry.com	self	Des Moines	IA	United States	Tricia Wilson	Jack Gradoville	Signed
349	2020-12-31 17:37	Anonymous (not verified)	107.77.161.33	JAG Painting	Proprietorship	1423 des moines street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-12-31	Berenice Silva	berenicesssvaldes@gmail.com	Des moines	Polk	IA	Manuel Aguilar	Luis Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Berenice Silva	berenicesssvaldes@gmail.com	Owner	Des moines	Polk	Iowa	Manuel Aguilar	Luis Garcia	Signed
264	2020-09-21 13:26	Anonymous (not verified)	107.77.173.3	JAG Painting	Proprietorship	1423 Des Moines Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-21	Berenice S Silva	berenicesssvaldes@gmail.com	Des Moines	Polk	Iowa	Luis Garcia	Maria Salas	Signed	(1) The employer does not elect the employers’ liability coverage.	Berenice S Silva	berenicesssvaldes@gmail.com	Owner	Des Moines	Polk	Iowa	Luis Garcia	Maria Salas	Signed
702	2021-11-01 09:23	Anonymous (not verified)	173.28.195.56	Garcia Snow Removal	Limited Liability Company	213 E 7th Street, West Liberty, Iowa 52776	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-01	Benji A Garcia	garciabenji23@gmail.com	West Liberty	IA	Norway	Luis Ordenana-Choez	Vicente Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Benji Garcia	garciabenji23@gmail.com	Member	West Liberty	Muscatine	Iowa	Luis Ordenana-Choez	Vicente Garcia	Signed
896	2022-02-04 11:58	Anonymous (not verified)	198.167.180.146	Northtowne Market Lot 7, LLC	Limited Liability Company	1005 Blairs Ferry Road NE, 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.	2022-02-04	Benjamin Wickum	bwickum@collinscu.org	CEDAR RAPIDS	Linn	Iowa	Jody Comried	Pat Milke	Signed	(1) The employer does not elect the employers’ liability coverage.	Benjamin Wickum	bwickum@collinscu.org	Manager	Cedar Rapids	Linn	Iowa	Jody Comried	Pat Milke	Signed
1394	2022-12-14 14:31	Anonymous (not verified)	74.84.121.206	Benjamin Salo	Proprietorship	320 Plat St Lansing, IA 52151	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-09	Benjamin Salo	benwa011@gmail.com	Lansing, Iowa	Allamakee	Iowa	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Benjamin Salo	benwa011@gmail.com	self	Lansing	Allamakee	Iowa	Chris Fye	Darrel Elsbernd	Signed
198	2020-07-08 17:35	Anonymous (not verified)	162.218.47.214	Olsem Aerial Application Services LLC	Limited Liability Company	34538 County Road 13 Westbrook MN 56183	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-08	Benjamin Olsem	oaasllc@gmail.com	Westbrook	Cottonwood	MN	Megan Olsem	Tobin Richards	Signed	(1) The employer does not elect the employers’ liability coverage.	Benjamin Olsem	oaasllc@gmail.com	Owner/Self	Westbrook	Cottonwood	MN	Megan Olsem	Tobin Richards	Signed
529	2021-05-24 16:16	Anonymous (not verified)	67.230.239.111	Olsem Aerial Application Services LLC	Limited Liability Company	34538 County Road 13 Westbrook, Minnesota 56183	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-24	Benjamin Olsem	oaasllC@gmail.com	Westbrook	Cottonwood	Minnesota	Megan Olsem	Jeff Oberg	Signed	(1) The employer does not elect the employers’ liability coverage.	Olsem Aerial Application Services LLC	oaasllc@gmail.com	Owner/Self	Westbrook	Cottonwood	Minnesota	Megan Olsem	Jeff Oberg	Signed
2245	2024-05-29 23:01	Anonymous (not verified)	94.188.205.168	Benjamin Kiel	Proprietorship	1820 West Benton St Unit 101, Iowa City, IA 52246	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-29	Benjamin Kiel	kielbenjamin11@gmail.com	Iowa City	Johnson	IA	Connor Littlefield	Nathan Wedel	Signed	(1) The employer does not elect the employers’ liability coverage.	Benjamin Kiel	kielbenjamin11@gmail.com	Self	Iowa City	Johnson	IA	Connor Littlefield	Nathan Wedel	Signed
1545	2023-03-29 20:15	Anonymous (not verified)	94.188.205.176	Leaf Filter LLC	Limited Liability Company	1595 georgetown road hudson ohio 44236	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-29	Benjamin Joseph Truitt	Bjt1228@yahoo.com	Springville	Linn	Iowa	Benjamin Joseph Truitt	Jordan Nisiewiczi	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewiczi	jnisiewicz@leafhome.com	Regional field recruiter 2	Riverside	Gallatin	Montana	Benjamin Joseph Truitt	Jordan Nisiewiczi	Signed
1292	2022-09-02 13:26	Anonymous (not verified)	173.20.146.6	Nicci Keck LLC	Limited Liability Company	1107 Pheasant Valley St, Iowa City, IA 52246	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-02	Benjamin Darbro	darbrob@gmail.com	Iowa City	Iowa	United States	Evangeline Kadera	Denise Kandel	Signed	(1) The employer does not elect the employers’ liability coverage.	Nicole Keck	niccikeckllc@gmail.com	Managing Member/Owner/President	Iowa City	Johnson	Iowa	Evangeline Kadera	Denise Kandel	Signed
569	2021-07-09 12:18	Anonymous (not verified)	173.17.250.209	Forest Ave Outreach dba Good Vibes Movement	Limited Liability Company	1600 6th Ave DSM IA 50314	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-09	Ben Spellman	ben@goodvibesmovement.org	Des Moines	IA	United States	Joel Donaghy	Brian Donaghy	Signed	(1) The employer does not elect the employers’ liability coverage.	Maya Bromolson	maya@goodvibesmovement.org	Executive Director	Des Moines	IA	United States	Joel Donaghy	Brian Donaghy	Signed
1626	2023-05-05 11:16	Anonymous (not verified)	94.188.205.166	I HAWK BUILDERS LLC	Limited Liability Company	1417 INDIAN HILLS DR SPIRIT LAKE, IA 51360	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-05	BEN BRANT	babrant99@yahoo.com	SPIRIT LAKE	DICKINSON	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	BEN BRANT	joel@walkerinsuranceia.com	SELF	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1387	2022-12-10 22:39	Anonymous (not verified)	98.156.163.144	Springfield Staffing Solution	Limited Liability Company	14918 Tuff Rd, Manor TX 78653	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-10	Beluchukwu Ebede	admin@springfield-staffing.com	Manor	Travis	United States	Oluchukwu Nwokoye	Beluchukwu Ebede	Signed	(1) The employer does not elect the employers’ liability coverage.	Beluchukwu Ebede	admin@springfield-staffing.com	Self	Manor	Travis	United States	Oluchukwu Nwokoye	Beluchukwu Ebede	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
1970	2023-12-29 10:01	Anonymous (not verified)	94.188.205.168	Beatrice Banura	Proprietorship	14511 Bentwood Dr, Urbandale IA 50323	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-29	Beatrice Banura	banurabeatrice4@gmail.com	Urbandale	Dallas	IA	Priscilla Saina	Gideon Saina	Signed	(1) The employer does not elect the employers’ liability coverage.	Beatrice Banura	banurabeatrice4@gmail.com	Self employed	Urbandale	IA	IA	Priscilla Saina	Gideon Saina	Signed
1990	2024-01-16 22:22	Anonymous (not verified)	94.188.205.168	DeltaPro Painting & Remodeling	Limited Liability Company	1115 Nolan Court North Liberty Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-16	Bayron Amador	bayronamador59@gmail.com	North Liberty	IA	Estados Unidos	Claudia Garmendia	Marlon Amador	Signed	(1) The employer does not elect the employers’ liability coverage.	Bayron Amador	bayronamador59@gmail.com	Owner/Employer	North Liberty	IA	Estados Unidos	Claudia Garmendia	Marlon Amador	Signed
599	2021-08-09 22:57	Anonymous (not verified)	70.39.22.76	The Bartman Express LLC	Limited Liability Company	1976 240th St. Bennett IA 52721	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-09	Barton Steines	bartmanexpress@gmail.com	Bennett	Cedar	Iowa	Robert Jarrett	Michael Sexton	Signed	(1) The employer does not elect the employers’ liability coverage.	Barton Steines	bartmanexpress@gmail.com	Self	Bennett	Cedar	Iowa	Robert Jarrett	Michael Sexton	Signed
1905	2023-11-13 21:35	Anonymous (not verified)	94.188.205.167	Bartolo Lopez	Limited Liability Company	2404 cass st Fort Worth tx 76112	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-13	Bartolo Lopez	bartololopez3737@gmail.com	Fort Worth tx	Tarrant county	Tx	Airan Zamudio	Carlos Lopez	Signed	(1) The employer does not elect the employers’ liability coverage.	Bartolo Lopez	bartololopez3737@mail.com	Boss of the company	Fort Worth	Tarrant county	Texas	Airan Zamudio	Carlos lopez	Signed
697	2021-10-28 15:30	Anonymous (not verified)	208.126.114.236	bartman express	Limited Liability Company	1976 240th st bennett iowa 52721	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-28	bartin joesph steines	bartmanexpress@gmail.com	bennett	cedar	iowa	Robert theordore jarrett	dana marie shipler	Signed	(1) The employer does not elect the employers’ liability coverage.	bartin joesph steines	bartmanexpress@gmail.com	self	bennett	cedar	iowa	robert theordore jarrett	dana marie shipler	Signed
106	2020-03-31 10:42	Anonymous (not verified)	209.152.77.101	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln ST., Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-31	Bart Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Janice Henningsen	Louise Helmke	Signed	(1) The employer does not elect the employers’ liability coverage.	Bart Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Janice Henningsen	Louise Helmke	Signed
461	2021-04-06 08:49	Anonymous (not verified)	209.152.77.101	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln ST., Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-06	Bart Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed	(1) The employer does not elect the employers’ liability coverage.	Bart Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed
975	2022-03-15 10:34	Anonymous (not verified)	209.152.77.101	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln ST., Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-15	Bart Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed	(1) The employer does not elect the employers’ liability coverage.	Bart Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed
1516	2023-03-14 09:00	Anonymous (not verified)	94.188.207.225	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln ST., Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-14	Bart Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed	(1) The employer does not elect the employers’ liability coverage.	Bart Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed
2140	2024-04-09 09:28	Anonymous (not verified)	94.188.205.175	Bart Fuller& James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln Street Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-09	Bart Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Kathryn Kelley	Janice Henningsen	Signed	(1) The employer does not elect the employers’ liability coverage.	Bart Fuller	goffins@ruthventel.com	Partner	Ruthven	PAlo Alto	Iowa	Kathryn Kelley	Janice Henningsen	Signed
1341	2022-10-23 14:31	Anonymous (not verified)	97.127.255.147	Traver Home Improvement	Limited Liability Company	14150 110 th Ave. Davenport, IA 52804	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-24	Barry S Traver	traverhomeimprovement@gmail.com	Davenport	IA	United States	Denise Baughman	Joni Bryant	Signed	(1) The employer does not elect the employers’ liability coverage.	Barry S Traver	traverhomeimprovement@gmail.com	self	Davenport	IA	United States	Denise Baughman	Joni Bryant	Signed
782	2021-12-08 10:11	Anonymous (not verified)	173.21.158.248	Barry Duncan	Proprietorship	2020 S.E. Four Seasons Dr., Ankeny IA 50021	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-08	BARRY DUNCAN	bduncan1452@gmail.com	Ankeny	IA	Iowa	Kathy Belieu	Summer Belieu-Slemp	Signed	(1) The employer does not elect the employers’ liability coverage.	BARRY DUNCAN	bduncan1452@gmail.com	Self	Ankeny	Polk	Iowa	Kathy Belieu	Summer Belieu-Slemp	Signed
41	2020-01-20 14:26	Anonymous (not verified)	173.24.181.211	BARBARA HOOGEVEEN	Proprietorship	304 MILL POND RD, 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.	2020-01-20	BARBARA HOOGEVEEN	MCGILLH@MTCNET.NET	ROCK RAPIDS	LYON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	BARABARA HOOGEVEEN	MCGILLH@MTCNET.NET	OWNER	ROCK RAPIDS	LYON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed
1384	2022-12-08 13:11	Anonymous (not verified)	172.58.81.43	Sehic G&S, LLC.	Limited Liability Company	4201 62nd st apt 4 Urbandale Ia 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-09	Bajro sehic	kalesija20@gmail.com	Urbandale	Polk	Iowa	N/A	N/A	Signed	(1) The employer does not elect the employers’ liability coverage.	Bajro sehic	kalesija20@gmail.com	Owner	Urbandale	Polk	Iowa	N/A	N/A	Signed
1395	2022-12-15 08:02	Anonymous (not verified)	172.58.84.122	Sehic G&S, LCC	Limited Liability Company	4201 62nd st Urbandale iowa 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-15	Bajro sehic	kalesija20@gmail.com	Urbandale	Polk	Iowa	Bajro	Bajro	Signed	(1) The employer does not elect the employers’ liability coverage.	Bajro sehic	kalesija20@gmail.com	Owner	Urbandale	Dallas	Iowa	Bajro	Bajro	Signed
737	2021-11-11 14:33	Anonymous (not verified)	72.13.16.172	BADGER COUNTRY TRUCKING LLC	Limited Liability Company	3877 US HWY 35 AND 61	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	BADGER COUNTRY TRUCKING LLC	dave@allseasonstrucking.com	POTOSI	GRANT	WI	Dave Neuwohner	BEN MOYER	Signed	(1) The employer does not elect the employers’ liability coverage.	BADGER COUNTRY TRUCKING LLC	dave@allseasonstrucking.com	PRESIDENT	POTOSI	GRANT	WI	Dave Neuwohner	BEN MOYER	Signed
2110	2024-03-21 13:29	Anonymous (not verified)	94.188.205.174	Baroga Stone Masonry LLC	Proprietorship	1228 Loomis Ave Des Moines, IA 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-21	Bacilio Rodriguez	barogastonemasonry@gmail.com	Des Moines	Polk	Iowa	Drakkar Rapaich	Fabi Palomares	Signed	(1) The employer does not elect the employers’ liability coverage.	Bacilio Rodriguez	barogastonemasonry@gmail.com	Self	Des Moines	Polk	Iowa	Drakkar Rapaich	Fabi Palomares	Signed
1578	2023-04-17 15:33	Anonymous (not verified)	94.188.205.174	Spark Train Express LLC	Limited Liability Company	16877 500th St, Pocahontas, IA 50574	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-17	Austin Sparks	sparksaustin.11@gmail.com	Pocahontas	Pocahontas	Iowa	Stephanie Webbink	Christian Lynch	Signed	(1) The employer does not elect the employers’ liability coverage.	Austin Sparks	sparksaustin.11@gmail.com	Owner	Pocahontas	Pocahontas	Iowa	Stephanie Webbink	Christian Lynch	Signed
1416	2023-01-09 13:05	Anonymous (not verified)	67.55.184.55	Austin Lanz	Proprietorship	3015 M Ave.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-09	Austin Robert Lanz	austinlanz52@gmail.com	Moring Sun	Iowa	IA	Robert Lowell Lanz	Jessica Leann Ewart	Signed	(1) The employer does not elect the employers’ liability coverage.	Austin Robert Lanz	austinlanz52@gmail.com	Self	Moring Sun	Iowa	IA	Robert Lowell Lanz	Jessica Leann Lanz	Signed
1952	2023-12-12 13:26	Anonymous (not verified)	94.188.205.167	Austin Albin	Proprietorship	2263 Railroad Street, Jacksonville, IL 62650	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-23	Austin R Albin	albinaustin12@gmail.com	Jacksonville	Morgan	IL	Wayne Albin	Jerry Roth	Signed	(1) The employer does not elect the employers’ liability coverage.	Austin R Albin	albinaustin12@gmail.com	Self	Jacksonville	Morgan	IL	Wayne Albin	Jerry Roth	Signed
933	2022-02-23 10:57	Anonymous (not verified)	104.37.139.87	Jacobsen Transfer	Limited Liability Company	1773 20th rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-23	Austin Moffat	austinmoffatt@gmail.com	tabor	von homme	south dakota	austin moffatt	jesse jacobsen	Signed	(1) The employer does not elect the employers’ liability coverage.	Jesse Jacobsen	jacobsentransfer@gmail.com	employee	bancorft	cuming	Nebraska	Jesse Jacobsen	Austin moffatt	Signed
1820	2023-08-28 08:12	Anonymous (not verified)	94.188.205.177	LLAD Services LLC	Limited Liability Company	1611 Esplanade Avenue Davenport IA 52803	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-28	Austin Lee Terry	austinfarrell92@gmail.com	Davenport	Scott	Iowa	Cody Dunbar	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	JNisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Cody Dunbar	Jordan Loyd	Signed
558	2021-07-07 13:35	Anonymous (not verified)	66.188.136.150	Austin Kalfus Sr.	Proprietorship	1203 Poppy Ave. Pensacola, FL 32507	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-07	Austin Kalfus Sr.	kschumacher@tricorinsurance.com	Pensacola	Escambia	FL	Mitch Kemp	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Austin Kalfus Sr.	kschumacher@tricorinsurance.com	Same	Pensacola	Escambia	FL	Mitch Kemp	Shuree Behr	Signed
1207	2022-07-15 10:02	Anonymous (not verified)	75.89.78.50	A&J Remodeling LLC	Limited Liability Company	2 Bungalow Ct Newton, Iowa 50208	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-15	Austin Hudson	ahudson7536@gmail.com	Newton	Jasper	IA	Liz Allen	Dustin Ingram	Signed	(1) The employer does not elect the employers’ liability coverage.	Austin Hudson	anjremodel@gmail.com	Co-owner	Newton	Jasper	IA	Liz Allen	Dustin Ingram	Signed
1324	2022-09-30 10:19	Anonymous (not verified)	172.86.18.249	Red Beard Buildings	Limited Liability Company	511 16th St. Belle Plaine, IA 52208	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-30	Austin Carnes	austin_carnes@hotmail.com	Belle Plaine	Benton	IA	Craig Roster	Connor Doran	Signed	(1) The employer does not elect the employers’ liability coverage.	Austin Carnes	austin_carnes@hotmail.com	President	Belle Plaine	Benton	IA	Craig Roster	Connor Doran	Signed
750	2021-11-16 12:34	Anonymous (not verified)	172.58.83.130	Austin Carlson	Proprietorship	1341 iron city avenue atalissa 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.	2021-11-16	Austin Carlson	toppeakconstruction@gmail.com	Atalissa	Muscating	Iowa	Jordan Nisiewicz	Sam Apponey	Signed	(1) The employer does not elect the employers’ liability coverage.	Jorden Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Jackson	Missouri	Jordan Nisiewicz	Sam Apponey	Signed
1188	2022-07-07 11:24	Anonymous (not verified)	107.117.176.70	Pitts Aerial Services LLC	Limited Liability Company	2478 county road 1488 Cullman al 35058	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-07	Austin Branch Pitts	pittsaerial@gmail.com	Cullman	Cullman	AL	Sydney Pitts	James Robertson	Signed	(1) The employer does not elect the employers’ liability coverage.	Austin Branch Pitts	pittsaerial@gmail.com	Owner	Cullman	Cullman	AL	Sydney Pitts	James Robertson	Signed
1189	2022-07-07 11:50	Anonymous (not verified)	71.91.55.59	Austin Branch Pitts	Proprietorship	2478 county road 1488 Cullman al 35058	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-07	Austin Branch Pitts	pittsaerial@gmail.com	Cullman	Cullman	AL	Sydney Pitts	James Robertson	Signed	(1) The employer does not elect the employers’ liability coverage.	Austin Branch Pitts	pittsaerial@gmail.com	Proprietor	Cullman	Cullman	AL	Sydney Pitts	James Robertson	Signed
2016	2024-02-01 09:20	Anonymous (not verified)	94.188.207.225	Imperium Outdoor Solutions	Proprietorship	114 W Clanton St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-01	Austin Beener	abeener033@gmail.com	St Charles	IA	United States	Austin Beener	Austin Beener	Signed	(1) The employer does not elect the employers’ liability coverage.	Austin Beener	abeener033@gmail.com	Operator	St Charles	IA	United States	Austin Beener	Austin Beener	Signed
128	2020-04-24 14:14	Anonymous (not verified)	173.21.123.73	JLC Finish Trim Carpenter inc	Proprietorship	2620 61st st des moines iowa 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-24	aura cordova mendoza	isabel_menro81@yahoo.com	des moines	polk	iowa	emily segura	roslyn duenas	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Mendoza	jlctrimcarpenterinc@gmail.com	employer	des moines	polk	iowa	emily segura	roslyn duenas	Signed
1738	2023-07-11 10:51	Anonymous (not verified)	94.188.207.224	Augustin Santos	Proprietorship	109 Loomis Ave Des Moines, Iowa 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-05	Augustin Santos	deb@piciowa.com	Des Moines	Polk	Iowa	Deb Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Augustin Santos	deb@piciowa.com	self	Des Moines	Polk	Iowa	Deb Stratton	Kelly Denger	Signed
2164	2024-04-19 13:52	Anonymous (not verified)	94.188.205.167	RKB Designs LLC	Limited Liability Company	4333 Cedar St, Davenport, IA 52806	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-19	Ashley Rocca	roccafive@gmail.com	Davenport	IA	United States	Nicholas Rocca	Joni Long	Signed	(1) The employer does not elect the employers’ liability coverage.	Ashley Rocca	roccafive@gmail.com	Self	Davenport	IA	United States	Nicholas Rocca	Joni Long	Signed
1376	2022-11-18 10:22	Anonymous (not verified)	166.181.87.119	Ashley Heffernen	Proprietorship	4009 Majestic Ct NE Cedar Rapids Iowa 52411	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-18	Ashley Rae Heffernen	ashley.heffernen@gmail.com	Cedar Rapids	Linn	Iowa	Kyle Reid	Amanda Frese	Signed	(1) The employer does not elect the employers’ liability coverage.	Ashley Rae Heffernen	ashley.heffernen@gmail.com	Self	Cedar Rapids	Linn	Iowa	Kyle Reid	Amanda Frese	Signed
1894	2023-11-03 10:02	Anonymous (not verified)	94.188.205.167	ASHLEY QUAIL DBA: RUSTIC ROOTS SALON	Proprietorship	33596 SCHANY DR, RUTHVEN, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-03	ASHLEY QUAIL	ashley-mazzanti@hotmail.com	RUTHVEN	PALO ALTO	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	ASHLEY QUAIL	ashley-mazzanti@hotmail.com	SELF	RUTHVEN	PALO ALTO	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1711	2023-06-26 16:50	Anonymous (not verified)	94.188.207.224	Innovative Behavioral Therapy, LLC	Limited Liability Company	915 Main St. 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.	2023-06-26	Ashley Andrew	ashley@innovativebehavioraltherapy.com	Adel	Dallas	Iowa	Thomas Atherton	Brenda Barto	Signed	(1) The employer does not elect the employers’ liability coverage.	Ashley Andrew	ashley@innovativebehavioraltherapy.com	Self	Adel	Dallas	Iowa	Thomas Atherton	Brenda Barto	Signed
672	2021-10-13 16:05	Anonymous (not verified)	75.162.218.218	Arturos Interiors LLC	Limited Liability Company	3305 se 22nd apt 15 Des Moines IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-29	Arturo mejia	arturomcruz20@hotmail.com	Des Moines	polk	IA	yolanda mendoza	liliana sanchez	Signed	(1) The employer does not elect the employers’ liability coverage.	Arturo Mejia	arturomcruz20@hotmail.com	member	Des Moines	polk	IA	Yolanda Mendoza	lialiana sanchez	Signed
584	2021-07-23 15:38	Anonymous (not verified)	75.162.41.54	Bradens Roofing & Construction LLc	Limited Liability Company	2450 Hart Ave, Des Moines, IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-23	Arsenio Vargas	avargas409@gmail.com	Des Moines	Polk	Iowa	Marc Black	Jason Anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Arsenio Vargas	avargas409@gmail.com	Owner	Des Moines	Polk	Iowa	Marc Black	Jason Anderson	Signed
1362	2022-11-08 08:36	Anonymous (not verified)	157.52.56.205	Martin Clip & Trim LLC	Proprietorship	Box 383 Urbana Iowa 52345	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-08	Armin Martin	arminbonnie@aol.com	Urbana	Benton	Iowa	Melissa Stieferman	Christin Martin	Signed	(1) The employer does not elect the employers’ liability coverage.	Armin Martin	arminbonnie@aol.com	Self	Urbana	Benton	Iowa	Melissa Stieferman	Christin Martin	Signed
704	2021-11-01 18:43	Anonymous (not verified)	157.52.56.205	Martin Clip & Trim LLC	Limited Liability Company	204 Oak Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-30	Armin Harold Martin	arminbonnie@aol.com	Urbana	Benton	Iowa	Melissa Linn Stieferman	Bronna Mae Gubbels	Signed	(1) The employer does not elect the employers’ liability coverage.	Armin Harold Martin	arminbonnie@aol.com	self	Urbana	Benton	Iowa	Melissa Linn Stieferman	Bronna Mae Gubbels	Signed
1026	2022-04-01 14:53	Anonymous (not verified)	173.31.148.43	ARMANDO RESENDEZ	Proprietorship	202 S 13TH ST APT #8 ESTHERVILLE, IA 51334	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-01	ARMANDO RESENDEZ	joel@walkerinsuranceia.com	Estherville	EMMET	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	ARMANDO RESENDEZ	joel@walkerinsuranceia.com	SELF	Estherville	EMMET	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed
2008	2024-01-29 14:45	Anonymous (not verified)	94.188.207.230	DB2P	Limited Liability Company	5904 Ashworth Road	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-29	Arjun Dahal	allcoolliquors@gmail.com	West Des Moines	Dallas	Iowa	Jayson Jones	Nikki Wilks	Signed	(1) The employer does not elect the employers’ liability coverage.	Jayson Jones	jayson@jonesinsured.com	Insurance Agent	Urbandale	Dallas	Iowa	Jayson Jones	Nikki Wilks	Signed
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
1628	2023-05-09 08:00	Anonymous (not verified)	94.188.205.175	Servin Drywall	Proprietorship	6311 Underwood 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.	2023-05-09	Arcel Servin	arcelservin77@gmail.com	Cedar Rapids	Linn	Iowa	Rolandas Bitanas	Kirk Strunk	Signed	(1) The employer does not elect the employers’ liability coverage.	Arcel Servin	arcelservin77@gmail.com	Self	Cedar Rapids	Linn	Iowa	Rolandas Bitanas	Kirk Strunk	Signed
1154	2022-06-14 00:27	Anonymous (not verified)	174.213.144.227	Arben Bahtirovic	Partnership	3060 South East Grimes Blvd, Suite 100-300 Grimes, Iowa 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-06-14	Arben Bahtirovic	arben2002@gmail.com	West Des Moines	Polk	IOWA	Senida bahtirovic	Mario mandic	Signed	(1) The employer does not elect the employers’ liability coverage.	Arben Bahtirovic	arben2002@gmail.com	Contractor	West Des Moines	Polk	IOWA	Senida bahtirovic	Marijo mandic	Signed
771	2021-11-22 20:29	Anonymous (not verified)	75.162.65.250	Art Flooring LLC	Limited Liability Company	1225 Emma Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-23	Antonio Rojas	artfloorsllc@gmail.com	1225 Emma Ave	Polk	Iowa	Antonio Rojas	Hilda Rojas	Signed	(1) The employer does not elect the employers’ liability coverage.	Antonio Rojas	artfloorsllc@gmail.com	self	same as above	same as above	iowa	Antonio Rojas	Hilda Rojas	Signed
2074	2024-03-04 16:56	Anonymous (not verified)	94.188.207.224	IG painting Llc	Limited Liability Company	416 51st ST West des moines,IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-01	antonio J Iglesias	antonio_joserene@hotmail.com	west Des moines	polk	iowa	Raul Gomez	Bruno Cruz	Signed	(1) The employer does not elect the employers’ liability coverage.	Antonio J Iglesias	antonio_joserene@hotmail.com	not relationship	West des Moines	polk	iowa	Raul Gomez	Bruno cruz	Signed
1693	2023-06-16 11:37	Anonymous (not verified)	94.188.207.230	Anthony Scroggins	Proprietorship	301 SE 11th Street , Unit 807	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-16	Anthony Scroggins	scroggins710@gmail.com	Grimes	Polk	IA	Cody Wavada	Nate Duden	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony Scroggins	scroggins710@gmail.com	Self	Grimes	Polk	IA	Cody Wavada	Nate Duden	Signed
1205	2022-07-14 13:29	Anonymous (not verified)	173.18.22.217	Residence Electric LLC	Limited Liability Company	5465 Mills Civic Pkwy #317 West Des Moines 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.	2022-07-14	Anthony Rivera	residenceelectric@outlook.com	West Des Moines	Polk	Iowa	Lesa Reeves	Erick Schuldt	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony Rivera	residenceelectric@outlook.com	Owner	West Des Moines	Polk	Iowa	Lesa Reeves	Erick Schuldt	Signed
2191	2024-04-29 10:09	Anonymous (not verified)	94.188.207.225	Anthony Rakestraw	Proprietorship	1262 S Kellogg St., Galesburg, IL 61401	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-29	Anthony Rakestraw	gazzork2@yahoo.com	Galesburg	Know	Illinois	Cheryl Ross	Larry Rheinschmidt	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony Rakestraw	gazzork2@yahoo.com	owner	Galesburg	Knox	Illinois	Cheryl Ross	Larry Rheinschmidt	Signed
1833	2023-09-08 13:39	Anonymous (not verified)	94.188.207.225	Superior painting & epoxy coatings llc	Limited Liability Company	4918 ne crestmoor ln	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-05	Anthony Negrete jr	superior.paint@hotmail.com	Ankeny	IA	United States	Stacey Marie stoecker	Anthony Negrete jr.	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony Negrete jr	superior.paint@hotmail.com	Spouse	Ankeny	IA	United States	Anthony Negrete jr	stacey marie Stoecker	Signed
1048	2022-04-14 14:17	Anonymous (not verified)	208.38.229.255	Mean Green Lawn Care	Limited Liability Company	2628 W 59th st Davenport Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-14	Anthony mccash	meangreenlawncare20@gmail.com	Davenport	Scott	Iowa	Clarissa Oliva	Julie Thornman	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony McCash	meangreenlawncare20@gmail.com	Owner	Davenport	Scott	Iowa	Clarissa Oliva	Julie Thornman	Signed
234	2020-08-18 09:13	Anonymous (not verified)	67.55.224.208	Anthony Keahi dba Hawaiian Handyman	Proprietorship	928 8th Ave SE, Sioux Center, IA 51250-2502	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-17	Anthony Keahi	hhkeahi@gmail.com	Sioux Center	Sioux	Iowa	Kyle Blankers	Julia Huisman	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony Keahi	hhkeahi@gmail.com	Self - sole proprietorship	Sioux Center	Sioux	Iowa	Kyle Blankers	Julia Huisman	Signed
2093	2024-03-13 15:53	Anonymous (not verified)	94.188.205.176	Tony Deutmeyer	Limited Liability Company	PO BOX 152 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.	2024-03-13	Anthony John Deutmeyer	tonydeutmeyer@gmail.com	Hiawatha	Linn	Iowa	Lacey riley	Andrew prochaska	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony Deutmeyer	tonydeutmeyer@gmail.com	Self	Hiawatha	Linn	Iowa	Lacey riley	Andrew prochaska	Signed
1483	2023-02-25 14:57	Anonymous (not verified)	94.188.205.168	Van Wyk Lawn Services	Limited Liability Company	14486 S. 128th ave E.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-24	Anthony Eugene Van Wyk	vanwykturf@gmail.com	Lynnville	Iowa	United States	Ashley Lynn Van Wyk	Abby Christine Peterson	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony Eugene Van Wyk	vanwykturf@gmail.com	Self/Owner	Lynnville	Iowa	United States	Ashley Lynn Van Wyk	Abby Christine Peterson	Signed
2199	2024-05-03 13:27	Anonymous (not verified)	94.188.207.228	Polar Delights LLC DBA Twists Ice Cream	Limited Liability Company	110 S 9th Ave Eldridge IA 52748	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-03	Anna Kokity	amkokity@gmail.com	Moline	Rock Island	IL	Ashley Schwien	Kasey Lange	Signed	(1) The employer does not elect the employers’ liability coverage.	Anna Kokity	amkokity@gmail.com	self	Moline	Rock Island	IL	Ashley Schwien	Kasey Lange	Signed
27	2020-01-06 09:17	Anonymous (not verified)	24.149.10.119	Miss Wonderful LLC	Limited Liability Company	216 Main St Cedar Falls, IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-06	Ann Eastman	misswonderful216@gmail.com	Cedar Falls	Black Hawk	IA	Rachel Lee	Ann Remmert	Signed	(1) The employer does not elect the employers’ liability coverage.	Ann Eastman	misswonderful216@gmail.com	Owner	Cedar Falls	Black Hawk	IA	Rachel Lee	Ann Remmert	Signed
625	2021-08-30 20:39	Anonymous (not verified)	173.16.140.101	Phthalo Consulting LLC	Limited Liability Company	2917 47th St, Des Moines, IA 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-30	Angela Stone-Wiegert	angela@phthaloconsulting.com	Des Moines	Polk	Iowa	Sonya Shippy	Kenny Shippy	Signed	(1) The employer does not elect the employers’ liability coverage.	Angela Stone-Wiegert	angela@phthaloconsulting.com	Owner	Des Moines	Polk	Iowa	Sonya Shippy	Kenny Shippy	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
76	2020-02-24 15:05	Anonymous (not verified)	97.64.133.18	Sky Roofing	Partnership	1332 Idaho St., Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-01	Angel Jurado	Liberty21424@gmail.com	des moines	Polk	Iowa	Valerie Cramer	David Murray	Signed	(1) The employer does not elect the employers’ liability coverage.	Cramer Law PLC	cramerlaw@halousa.com	Attorney	Polk	Polk	Iowa	Sara Mc Ginnis	David Murray	Signed
267	2020-09-22 07:04	Anonymous (not verified)	74.84.65.174	Angel Jesus Argueta	Proprietorship	1523 Arlington Ave Des Moines, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-22	Angel Jesus Argueta	Juanargueta22@yahoo.com	Des Moines	Polk	Iowa	Larry Eugene Guire	Eric Michael West	Signed	(1) The employer does not elect the employers’ liability coverage.	Angel Jesus Argueta	Juanargueta22@yahoo.com	Same	Des Moines	Polk	Iowa	Larry Eugene Guire	Eric Michael West	Signed
1237	2022-08-01 22:40	Anonymous (not verified)	50.80.97.239	Andy Fiala	Proprietorship	1628 34th St. NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-01	Andy W Fiala	fialaandy1@gmail.com	Cedar Rapids	IA	United States	John A Hasson	Scott M Fiala	Signed	(1) The employer does not elect the employers’ liability coverage.	Andy W Fiala	fialaandy1@gmail.com	Owner	Cedar Rapids	IA	United States	John A Hasson	Scott M Fiala	Signed
1844	2023-09-14 14:15	Anonymous (not verified)	94.188.205.177	Royal Gutters & Construction, LLC	Limited Liability Company	1420 120th Street, Hazleton, IA 50641	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-01	Andy Hershberger	hershbergera@gmail.com	Hazleton	Buchanan	Iowa	Eli Raber	Steve Frost	Signed	(1) The employer does not elect the employers’ liability coverage.	Andy Herschberger	hershbergera@gmail.com	self	Hazleton	Buchanan	Iowa	Eli Miller	Steve Frost	Signed
864	2022-01-27 12:50	Anonymous (not verified)	67.55.155.207	Chamra Farms	Limited Liability Company	3031 215 th 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.	2022-01-01	Andy Chamra	apchamra@gmail.com	Rose Hill	Iowa	United States	Steve Weller	Connie VanKlootwyk	Signed	(1) The employer does not elect the employers’ liability coverage.	Steven Weller	steve.weller@insurancestationinc.com	Agent	OSKALOOSA	Iowa	United States	Andy Chamra	Connie Van Klootwyk	Signed
557	2021-07-07 09:51	Anonymous (not verified)	66.188.136.150	Andrew Thompson-Sutherland	Proprietorship	3200 Daniel Lane Apt. 207 Monroeville, PA 15146	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-06	Andrew Thompson-Sutherland	kschumacher@tricorinsurance.com	Monroeville	Allegheny	PA	Mitch Kemp	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Thompson-Sutherland	kschumacher@tricorinsurance.com	Same	Monroeville	Allegheny	PA	Mitch Kemp	Shuree Behr	Signed
2166	2024-04-20 13:38	Anonymous (not verified)	94.188.205.175	Cedar Valley Seamless, LLC	Limited Liability Company	1184 215th St, Jesup, IA 50648	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-20	Andrew Richard Trumbauer	cedarvalleyseamlessllc@gmail.com	Jesup	Buchanan	Iowa	James William Masteller	Andrew William Hamilton	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Richard Trumbauer	cedarvalleyseamlessllc@gmail.com	Owner/Operator	Jesup	Buchanan	Iowa	James William Masteller	Andrew William Hamilton	Signed
1461	2023-02-17 07:48	Anonymous (not verified)	94.188.205.168	Great Blinds LLC	Limited Liability Company	5174 Parkridge Ave Pleasant Hill, IA 50327	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-17	Andrew Mohrfeld	mohrfeldandy@yahoo.com	Pleasant Hill	Polk	IA	Andrew Mohrfeld	Martin Mohrfeld	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	John Lovell	Jon@jlovellco.com	None	Urbandale	Polk	IA	Andrew Mohrfeld	Martin Mohrfeld	Signed
2154	2024-04-16 08:05	Anonymous (not verified)	94.188.207.226	Lanz Pork Inc	Proprietorship	12905 N 1050th Road, Macomb, IL 61455	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Andrew M Riggins	kellylanz1967@gmail.com	Macomb	IL	United States	Barb Coker	Scott Caspall	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew M Riggins	kellylanz1967@gmail.com	Self	Macomb	IL	United States	Barb Coker	Scott Caspall	Signed
2155	2024-04-16 08:13	Anonymous (not verified)	94.188.207.225	Andrew M Riggins	Proprietorship	12905 N 1050th Road, Macomb, IL 61455	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Andrew M Riggins	kellylanz1967@gmail.com	Macomb	IL	United States	Barb Coker	Scott Caspall	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew M Riggins	kellylanz1967@gmail.com	Self	Macomb	IL	United States	Barb Coker	Scott Caspall	Signed
1733	2023-07-10 14:30	Anonymous (not verified)	94.188.205.177	Leaf home	Proprietorship	1595 Georgetown Rd., Hudson, OH 44236	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-10	Andrew Koske	aokoz_23@outlook.com	East Moline	IL	United States	Andrew Koske	Andrew Koske	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Koske	aokoz_23@outlook.com	None	East Moline	IL	United States	Andrew Koske	Andrew Koske	Signed
1651	2023-05-16 22:18	Anonymous (not verified)	94.188.205.175	Corridor Cleaning Services, LLC	Limited Liability Company	4621 Orchard Dr NW, Cedar Rapids, Iowa, 52405	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-11	Andrew Kleineck	andrew@corridorcleaning.net	Cedar Rapids	Linn	Iowa	Cole Smith	Suzanne Brue	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Kleineck	andrew@corridorcleaning.net	LLC Member	Cedar Rapids	Linn	Iowa	Cole Smith	Suzanne Brue	Signed
2243	2024-05-29 10:22	Anonymous (not verified)	94.188.205.168	Andrew Kafeero	Proprietorship	3201 Sylvania dr west des moines iowa 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.	2024-05-29	Andrew Kafeero	andrewkafeero@yahoo.com	West desmoines	Iowa	United States	jeseph ssekibuule	rebecca namugabi	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Kafeero	andrewkafeero@yahoo.com	Self	West desmoines	Iowa	United States	joseph ssekibuule	rebecca namugabi	Signed
1852	2023-09-24 16:02	Anonymous (not verified)	94.188.205.174	Handy Andy Enterprises LLC	Limited Liability Company	PO Box 479, Williamsburg, Iowa 52361	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-01	Andrew J Garner	andy@handyandyenterprises.net	Williamsburg	Iowa	Iowa	Amanda Bowen	Kent Pope	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew J Garner	agarner6977@gmail.com	Owner	Williamsburg	Iowa	Iowa	Amanda Bowen	Kent Pope	Signed
1813	2023-08-22 15:44	Anonymous (not verified)	94.188.205.176	Hart and Company	Limited Liability Company	PO Box 757 Indianola IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-22	Andrew Hart	hartinnovate@gmail.com	Ackworth	Warren	Iowa	John M Keller	Logan David	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Hart	hartinnovate@gmail.com	Self	Ackworth	Warren	Iowa	John M Keller	Logan David	Signed
456	2021-04-02 10:02	Anonymous (not verified)	207.177.7.191	Goettsch Dispatch Inc	Limited Liability Company	200 Main St Galva, IA 51020	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-15	Andrew Goettsch	andygoettsch@gmail.com	Galva	Ida	Iowa	Kristy Dewey	Terri Ullrich	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Goettsch	andygoettsch@gmail.com	President	Galva	Ida	Iowa	Kristy Dewey	Terri Ullrich	Signed
453	2021-03-26 08:27	Anonymous (not verified)	192.30.185.142	DYAD LLC	Partnership	2308 Summit St, Sioux City, IA 51104	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-26	Andrew Glisar	john@kellyconstruction.com	Sioux City	Woodbury	IA	Katie Jenks	Jenni Ebner	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Glisar	john@kellyconstruction.com	Owner/Partner	Sioux City	Woodbury	IA	Katie Jenks	Jenni Ebner	Signed
1084	2022-05-02 15:23	Anonymous (not verified)	173.23.196.11	Sweet Green Arborist Services, LLC	Limited Liability Company	804 W. Briggs Ave, Fairfield, IA 52556	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-02	Andrew Forest Nash	sweetgreenarborist@gmail.com	Fairfield	Jeffereson	Iowa	Eli Morgan	Rachel Morgan	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Nash	anash66@gmail.com	same	Fairfield	Jeffereson	Iowa	Rachel Morgan	Eli Morgan	Signed
255	2020-09-11 13:42	Anonymous (not verified)	173.190.65.6	A Fisk Trucking, LLC	Limited Liability Company	PO Box 332, Strawberry Point, IA 52076	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-14	Andrew Fisk	afisktrucking@gmail.com	Strawberry Point	Clayton	Iowa	Pamela Vaske	Crystal Thole	Signed	(1) The employer does not elect the employers’ liability coverage.	A Fisk Trucking, LLC	afisktrucking@gmail.com	Member/Manager	Strawberry Point	Clayton	Iowa	Pamela Vaske	Crystal Thole	Signed
1277	2022-08-22 08:57	Anonymous (not verified)	68.169.247.177	Andrew Betts	Proprietorship	305 3rd ave sw cascade ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-22	Andrew Betts	dbidrywallco@gmail.com	Cascade	Dubuque	Iowa	Jamie manternach	Andy hall	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Betts	dbidrywallco@gmail.com	Owner	Cascade	Iowa	United States	Jamie manternach	Andy hall	Signed
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
1509	2023-03-09 10:39	Anonymous (not verified)	94.188.207.227	Andres Barboza	Limited Liability Company	329 West 31 St South Sioux city ne 68776	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-09	Andres Barboza	barboza79@yahoo.com	South Sioux City	Nebraska	United States	Jaime Gutierrez	Gerardo ibarra	Signed	(1) The employer does not elect the employers’ liability coverage.	Andres Barboza	barboza79@yahoo.com	Owner	South Sioux City	Nebraska	United States	Jaime Gutierrez	Gerardo ibarra	Signed
1639	2023-05-11 07:39	Anonymous (not verified)	94.188.205.175	JYC Drywall LLC	Proprietorship	1034 Grand Ave, Muscatine, IA 52761	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Anastacio Zamarripa	1zama0081@gmail.com	Muscatine	Louisa	Iowa	Arcel Servin	Chris Hay	Signed	(1) The employer does not elect the employers’ liability coverage.	Anastacio Zamarripa	1zama0081@gmail.com	Self	Muscatine	Louisa	Iowa	Arcel Servin	Chris Hay	Signed
63	2020-02-17 16:05	Anonymous (not verified)	173.17.12.213	ANA GARCIA GONZALEZ	Limited Liability Company	4023 14TH ST DES MOINES IOWA 50313	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-17	Ana Garcia Gonzalez	gjeanettegonzalez@gmail.com	DES MOINES	POLK	IOWA	LUZ SAUCEDA	SANDRA ISABEL SAUCEDA	Signed	(1) The employer does not elect the employers’ liability coverage.	ANA GARCIA GONZALEZ	GJEANETTEGONZALEZ@GMAIL.COM	SELF	DES MOINES	POLK	IA	LUZ SOTELO SAUCEDO	SANDRA ISABEL SAUCEDA	Signed
333	2020-12-05 08:57	Anonymous (not verified)	173.25.143.97	Groen Pediatric Consulting	Limited Liability Company	1206 NE 31ST ST Ankeny, IA 50021	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-01	Amy Groen	dramygroen@yahoo.com	Ankeny	Iowa	United States	Daniel Martin	Anita Anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Amy Groen	dramygroen@yahoo.com	self	Ankeny	Iowa	United States	Kay Martin	Priscilla Putzier	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
688	2021-10-25 10:56	Anonymous (not verified)	75.91.173.195	Ami Westcott	Proprietorship	2672 F 52 Trail Parnell, IA 52325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Ami Lynn Westcott	ami.westcott@gmail.com	Parmell	Iowa	Iowa	Donald Scott Westcott	Andrew Patrick Brummel	Signed	(1) The employer does not elect the employers’ liability coverage.	Ami Lynn Westcott	ami.westcott@gmail.com	self	Parnell	Iowa	Iowa	Donald Scott Westcott	Andrew Patrick Brummel	Signed
191	2020-06-23 16:09	Anonymous (not verified)	173.18.3.76	Look At You LLC	Limited Liability Company	5545 Mills Civic Pkwy Ste 100 West Des Moines, IA 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-23	Amber Keppler	keppler_ark@outlook.com	Des Moines	Polk	IA	Angela Kinsey	Jon Stetzel	Signed	(1) The employer does not elect the employers’ liability coverage.	Amber Keppler	keppler_ark@outlook.com	LLC Member	Des Moines	Polk	IA	Angela Kinsey	Jon Stetzel	Signed
19	2019-12-31 16:29	Anonymous (not verified)	172.58.83.45	A.M. Tile	Proprietorship	3824 122nd 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.	2019-12-31	Amar Music	amarmusic01@gmail.com	Urbandale	IA	United States	Sefik Music	Amara Crncevic	Signed	(1) The employer does not elect the employers’ liability coverage.	Amar Music	amarmusic01@gmail.com	Owner	Urbandale	IA	United States	Sefik Music	Amara Crncevic	Signed
20	2019-12-31 16:36	Anonymous (not verified)	172.58.83.45	A.M. Tile	Proprietorship	3824 122nd 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.	2019-12-31	Amar Music	amarmusic01@gmail.com	Urbandale	IA	United States	Sefik Music	Amara Crncevic	Signed	(1) The employer does not elect the employers’ liability coverage.	Omer Okic	ultimate.exteriors@gmail.com	Owner	Des Moines	Polk	IA	Sefik Music	Amara Crncevic	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
1421	2023-01-13 09:43	Anonymous (not verified)	96.18.190.183	Home Base Inspection & Code Services, LLC	Limited Liability Company	3805 Ridge Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-13	Amanda Harper	amanda@hbicsvs.com	Sioux City	IA	United States	Terri Harper	Joy Brouilette	Signed	(1) The employer does not elect the employers’ liability coverage.	Amanda Harper	amanda@hbicsvs.com	self	Sioux City	IA	United States	Terri Harper	Joy Brouillette	Signed
44	2020-01-28 12:55	Anonymous (not verified)	173.24.181.211	AMANDA FIEDLER	Proprietorship	10 5TH AVE NW FOSTORIA, IA 51340	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-28	AMANDA FIEDLER	JOEL@WALKERINSURANCEIA.COM	FOSTORIA	CLAY	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	AMANDA FIEDLER	JOEL@WALKERINSURANCEIA.COM	OWNER	FOSTORIA	CLAY	IA	JOSPH THOMAS LORING	TAMI SUE KLEIN	Signed
1257	2022-08-15 13:27	Anonymous (not verified)	173.29.47.222	Premiere Plastering & Drywall, Inc.	Proprietorship	2331 W. 63rd St., Davenport, IA 52806	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-08-15	Amanda Carol Loeffelholz	evansamanda300@yahoo.com	Davenport	Iowa	United States	Jamie Wardlow	Kandra Blumenshein	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Premiere Plastering & Drywall, Inc.	premiere_pd_llc@yahoo.com	Subcontractor	Davenport	Iowa	United States	Jamie Wardlow	Kandra Blumenshein	Signed
2251	2024-05-31 09:40	Anonymous (not verified)	94.188.205.167	Vibrant SCL	Limited Liability Company	1776 22nd Street STE 202 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.	2024-05-31	Alyssa Wittenburg	alyssa85@live.com	Iowa	Johnson	Iowa	Alyssa Wittenburg	Alyssa Wittenburg	Signed	(1) The employer does not elect the employers’ liability coverage.	Vibrant SCL	tcarew@vibrant-llc.com	VP	West Des Moines	Poke	Iowa	Alyssa WIttenburg	Alyssa Wittenburg	Signed
1673	2023-06-02 09:30	Anonymous (not verified)	94.188.207.228	Kacena Family Tree Farm Inc	Partnership	2510 55th St., Vinton, IA 52349	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-01	Alyce Lynch	kacenafarms.alyce@gmail.com	Vinton	Benton	Iowa	Ashlyn J. Christianson	Angie McFarland	Signed	(1) The employer does not elect the employers’ liability coverage.	Alyce Lynch	ashlyn@3riversins.net	25% Owner - President	Vinton	Benton	Iowa	Ashlyn J. Christianson	Angie McFarland	Signed
1065	2022-04-21 16:26	Anonymous (not verified)	172.58.84.198	Royal Flooring	Limited Liability Company	11801 Hickman Rd Urbandale Iowa 50323	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-21	Alondra Canedo Orta	alondracanedo34@gmail.com	Des Moines	Polk county	Iowa	Alondra Canedo	Marvin Bonilla	Signed	(1) The employer does not elect the employers’ liability coverage.	Royal Flooring	Workorders@shoproyalflooring.com	Employee	Des Moines	Polk county	Iowa	Alondra Canedo	Marvin Bonilla	Signed
1068	2022-04-25 06:07	Anonymous (not verified)	172.58.84.213	Alondra Canedo Orta	Limited Liability Company	4100 Hubbell Ave Apt#80 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.	2022-04-25	Alondra Canedo Orta	alondracanedo34@gmail.com	Des Moines	Polk county	Iowa	Marvin Bonilla	Alondra Canedo	Signed	(1) The employer does not elect the employers’ liability coverage.	Alondra Canedo Orta	alondracanedo34@gmail.com	Subcontractor Installer	Des Moines	Polk county	Iowa	Marvin Bonilla	Alondra Canedo	Signed
979	2022-03-15 13:48	Anonymous (not verified)	72.255.78.146	Custom Climates	Partnership	3305 Highway 1 SW Ste 9A Iowa City IA 52240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-15	Allen Nichols	ranichols4@gmail.com	CEDAR RAPIDS	Iowa	IA	Rose Nichols	Rose Nichols	Signed	(1) The employer does not elect the employers’ liability coverage.	Allen Nichols	ranichols4@gmail.com	spouse	CEDAR RAPIDS	Iowa	IA	Rose Nichols	Rose Nichols	Signed
39	2020-01-19 11:00	Anonymous (not verified)	75.163.84.145	Allen L Bryen	Proprietorship	2609 Madison St Bellevue NE 68005	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-19	Allen Lee Bryen	Allen.Bryen@yahoo.com	Bellevue	Sarpy	Nebraska	Jeffrey Coats	Donald Coats	Signed	(1) The employer does not elect the employers’ liability coverage.	Allen L Bryen	Allen.Bryen@yahoo.com	Self	Bellevue	Sarpy	Nebraska	jeffrey Coats	Donald Coats	Signed
1473	2023-02-20 15:57	Anonymous (not verified)	94.188.207.224	C & A Fox Farms LLC	Limited Liability Company	3275 valley Ave Orchard IA 50460	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-20	Allen Fox	sales@foxfarmsllc.com	Orchard	Mitchell	Iowa	Darrel Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Allen Fox	sales@foxfarmsllc.com	self	Orchard	Mitchell	Iowa	Darrel Elsbernd	Chris Fye	Signed
1949	2023-12-11 15:20	Anonymous (not verified)	94.188.207.223	Allens construction services llc	Limited Liability Company	509 Nw Scott St Ankeny, Iowa 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-11	Allen Cheville	acsllc515@gmail.com	Ankeny	Polk	IOWA	Allen Cheville	Alexis Zimmerman	Signed	(1) The employer does not elect the employers’ liability coverage.	Allen Cheville	acsllc515@gmail.com	Self	Ankeny	Polk	IOWA	Allen Cheville	Alexis Zimmerman	Signed
1276	2022-08-19 13:43	Anonymous (not verified)	173.29.47.222	Premiere Plastering & Drywall, Inc.	Proprietorship	2331 W. 63rd St., Davenport, IA 52806	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-08-19	Allen Aldridge	allenaldridge73@yahoo.com	Davenport	Scott	Iowa	Jamie Wardlow	Kandra Blumenshein	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Premiere Plastering & Drywall, Inc.	premiere_pd_llc@yahoo.com	Subcontractor	Davenport	Scott	Iowa	Jamie Wardlow	Kandra Blumenshein	Signed
646	2021-09-20 08:54	Anonymous (not verified)	173.24.107.209	QCA Professional Contractors	Limited Liability Company	3314 67th Ave, Moline, IL. 61265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-20	Allan Celada	allancelada@qcaprocontractors.com	Moline	Rock Island	IL	Alexander Celada	Drexel Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Allan Celada	allancelada@qcaprocontractors.com	self	Moline	Rock Island	IL	Alexander Celada	Drexel Miller	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
2071	2024-03-01 11:08	Anonymous (not verified)	94.188.207.229	Level92 Screen Printing LLC	Limited Liability Company	2500 W 2nd Ave Ste 10, Indianola, IA 50125	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-01	Alison Vice	orders@level92.com	Indianola	Warren	IA	Jake Vice	Grant Darrah	Signed	(1) The employer does not elect the employers’ liability coverage.	Alison Vice	orders@level92.com	Partner	Indianola	Warren	IA	Jake Vice	Grant Darrah	Signed
1586	2023-04-19 08:38	Anonymous (not verified)	94.188.205.169	Arcos Siding, LLC	Limited Liability Company	1429 22nd Street, Des Moines, IA 50311	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-19	Alfredo Arco Cruz	alfredoarcos13@gmail.com	Des Moines	Polk	Des Moines	Maria Sevillana Cruz	Miguel Sevillana	Signed	(1) The employer does not elect the employers’ liability coverage.	Alfredo Arcos Cruz	alfredoarco13@gmail.com	Self	Des Moines	Polk	Iowa	Maria Sevillana Cruz	Miguel Sevillana	Signed
691	2021-10-26 14:54	Anonymous (not verified)	65.144.174.26	Alfonso Montoya	Proprietorship	2114 Nw Maple St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-26	Alfonso Montoya	fonzflooring@gmail.com	Des Moines	Polk	Iowa	Hector Montoya	Victor Montoya	Signed	(1) The employer does not elect the employers’ liability coverage.	Alfonso Montoya	fonzflooring@gmail.com	Owner	Des Moines	Polk	Iowa	Hector Montoya	Victor Montoya	Signed
2048	2024-02-16 07:42	Anonymous (not verified)	94.188.207.224	Alexandra Machedon LLC	Proprietorship	319 N Western Street Stuart, IA 50250	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-16	Alexandra Machedon	ali@alimachedon.com	Stuart	USA	Iowa	Jessica Cash	Vicki Collins	Signed	(1) The employer does not elect the employers’ liability coverage.	Alexandra Machedon	ali@alimachedon.com	Self	Stuart	US	IA	Jessi Cash	Vicki Collins	Signed
531	2021-05-26 13:02	Anonymous (not verified)	75.162.156.185	Xander Wessels	Limited Liability Company	719 10TH ST NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-26	Alexander Wessels	kprepair@outlook.com	MASON CITY	IA	IA	Dusty Howe	Sadie Lonning	Signed	(1) The employer does not elect the employers’ liability coverage.	Dusty Howe	dusty.mcelectric@gmail.com	Sub Contractor	Mason City	Cerro Gordo	Iowa	Dusty Howe	Sadie Lonning	Signed
533	2021-06-03 20:37	Anonymous (not verified)	75.162.171.128	KP Repair LLC	Limited Liability Company	719 10th St. NE Mason 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.	2021-06-03	Alexander Wessels	kprepair@outlook.com	MASON CITY	Cerro Gordo	IA	Sadie Lonning	Dusty Howe	Signed	(1) The employer does not elect the employers’ liability coverage.	Alexander Wessels	kprepair@outlook.com	Owner	MASON CITY	Cerro Gordo	IA	Sadie Lonning	Dusty Howe	Signed
1454	2023-02-14 09:34	Anonymous (not verified)	94.188.207.227	Spencer Imaging Center, LLC	Limited Liability Company	710 S. Grand Ave., 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.	2023-02-14	Alexander Pruitt	apruitt@ncn.net	Spencer	Clay	IA	Shanna Marie Kooker	Chad Roemeling	Signed	(1) The employer does not elect the employers’ liability coverage.	William Muller	mullerwilliam@hotmail.com	Co owner	Spencer	Clay	IA	Shanna Marie Kooker	Chad Roemeling	Signed
1322	2022-09-27 11:31	Anonymous (not verified)	96.31.4.134	Owens Inspection Services	Limited Liability Company	598 2nd Street SE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-01	Alexander Patrick Owe s	ap_owens_14@yahoo.com	Hospers	Sioux	Iowa	Michael Vander Wilt	Shane Meendering	Signed	(1) The employer does not elect the employers’ liability coverage.	Donald Patrick Owens	dpowens@premieronline.net	Owner	Sioux Center	Sioux	Iowa	Michael Vander Wilt	Shane Meendering	Signed
452	2021-03-26 07:30	Anonymous (not verified)	173.31.109.49	Rogers Concrete Construction	Partnership	22802 County Rd E34	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-26	Alexander Olah	aolah43@gmail.com	Cedar Rapids	Linn	Iowa	Robin Marie Kane	Augies Rodrigez	Signed	(1) The employer does not elect the employers’ liability coverage.	Kevin Johnson	kevinjohnson@libertymutual.com	Insurance Agent	Appleton	Outagamie	Wisconsin	Robin Marie Kane	Augie Rodrigez	Signed
2249	2024-05-30 14:36	Anonymous (not verified)	94.188.205.175	The Spot Nutrition, LLC	Limited Liability Company	357 Main Street Suite B 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.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2024-05-30	Alexander Lee	thespotnutritiondbq@yahoo.com	Dubuque	Dubuque	Iowa	Angela Watkins	Morgan Brimeyer	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Lane Madsen	lane.madsen.vaakad@statefarm.com	Client	Dubuque	Dubuque	Iowa	Angela Watkins	Morgan Brimeyer	Signed
1746	2023-07-14 09:21	Anonymous (not verified)	94.188.205.176	Alex Webb	Proprietorship	4019 West Roderweis Road Cabot Ar 72023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-14	Alex Webb	frankie.webb@yahoo.com	Cabot	Pulaski	Arkansas	Mark Ellis	Becky Ellis	Signed	(1) The employer does not elect the employers’ liability coverage.	Ellis Flying Service INC.	fly@ellisflying.com	President	Newport	Arkansas	United States	Alex Webb	Becky Ellis	Signed
296	2020-10-29 09:39	Anonymous (not verified)	174.243.81.9	Alex Vanderbeek	Proprietorship	85 NE Grace Wood Drive, Waukee, Iowa 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-29	Alex Vanderbeek	Vanderbeek17151@gmail.com	Waukee	Dallas	Iowa	Joe Simpson	James Nelson	Signed	(1) The employer does not elect the employers’ liability coverage.	Alex Vanderbeek	Vanderbeek17151@gmail.com	self	WAUKEE	IA	United States	Joe Simpson	James Nelson	Signed
469	2021-04-12 16:49	Anonymous (not verified)	65.103.82.36	Stice Construction	Proprietorship	13723 140th st W	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-07-22	Alex Stice	Astice17@hotmail.com	Taylor Ridge	Rock Island	IL	Ashley Stice	JIm Stice	Signed	(1) The employer does not elect the employers’ liability coverage.	Alex Stice	astice17@hotmail.com	self	taylor ridge	rock island	il	Ashley stice	Jim Stice	Signed
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
1629	2023-05-09 08:50	Anonymous (not verified)	94.188.207.223	Alex Jones	Proprietorship	2423 Glass Road Northeast, Cedar Rapids, IA 52402, United State	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-09	Alex Jones	ajones0425@yahoo.com	Cedar Rapids	Linn	Iowa	Jordan Nisiewicz	Charles Wood	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Jordan Loyd	Charles Wood	Signed
567	2021-07-08 14:22	Anonymous (not verified)	50.82.130.211	Black Cat Ice Cream, LLC	Limited Liability Company	1031 Office Park Road, Suite #4, 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.	2021-06-10	Alex Carter	cmins_re@mchsi.com	Des Moines	Polk	Iowa	Mary Brown	Kaytee Stearns	Signed	(1) The employer does not elect the employers’ liability coverage.	Black Cat Ice Cream, LLC	cmins_re@mchsi.com	Self	Des Moines	Polk	Iowa	Mary Brown	Kaytee Stearns	Signed
1155	2022-06-14 12:44	Anonymous (not verified)	207.45.82.36	GREEN AND SHINE SERVICES INC	Proprietorship	210 Ne 41st st Apt 203 Ankeny, IA, 50021	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-14	ALEX A. LOPEZ REDONDO	greenandshineservices@gmail.com	ankeny	polk	iowa	Giselle roa	Marta casado	Signed	(1) The employer does not elect the employers’ liability coverage.	Alex A Lopez Redondo	greenandshineservices@gmail.com	propery	ankeny	polk	iowa	Giselle Roa	Marta Casado	Signed
451	2021-03-25 17:00	Anonymous (not verified)	166.181.80.120	Rogers conc,. const,	Partnership	220804 CO, RD, ANAMOSA IA, 52205	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-25	Alex olah	aolah43@gmail.com	Cedar Rapids	Linn	Iowa	Robin marie kane	Augie rodreguez	Signed	(1) The employer does not elect the employers’ liability coverage.	Kevin johnson	kevinecollins@libertymutual.com	Ins , Agent	Appleton	Dane	Wisconsin	Robin marie kane	Augie Rodriguez	Signed
1406	2023-01-04 11:58	Anonymous (not verified)	67.55.135.18	Duncan Home Services LLC	Limited Liability Company	2543 Cottage 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.	2022-01-04	Alethea Anne Duncan	projects@duncanhs.com	Waverly	IA	United States	Travis Duncan	Kristine Fisher	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Duncan	projects@duncanhs.com	spouse	Waverly	IA	United States	Travis Duncan	Kristine Fisher	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
1468	2023-02-17 16:17	Anonymous (not verified)	94.188.207.230	AJ Cook LLC	Limited Liability Company	1817 Redbud Street, Norwalk, IA 50211	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-17	Alejandro Cook	alejandro.cook14@gmail.com	Norwalk	Warren	Iowa	Steve Bieghler	Nichole Bishop	Signed	(1) The employer does not elect the employers’ liability coverage.	Alejandro Cook	alejandro.cook14@gmail.com	Self	Norwalk	Warren	Iowa	Steve Bieghler	Nichole Bishop	Signed
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
2255	2024-06-02 16:03	Anonymous (not verified)	94.188.205.174	Guadalajara jalisco llc	Limited Liability Company	1334 e 9 th st des moines ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-06-02	Alejandra Reyes Rodriguez	josegarcia120679@gmail.comdes	Iowa	Des moines	Usa	Juan Dominguez	Ricardo Rodriguez	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose garcia	Josegarcia120679@gmail.com	Esposo	Iowa	Des moines	Usa	William Rodriguez	Jorge corona	Signed
448	2021-03-25 10:18	Anonymous (not verified)	172.58.83.161		Limited Liability Company	201 Ne 44th St , Apt 111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-25	Aldo Monroy reyes	Aldogmonroy@gmail.com	Ankeny	Polk county	IOWA	Elizabeth lopez	Brayan monroy	Signed	(1) The employer does not elect the employers’ liability coverage.	Aldo Monroy	Aldogmonroy@gmail.com	None	Ankeny	Polk county	IOWA	Aldo Monroy	Brayan monroy	Signed
508	2021-05-10 11:56	Anonymous (not verified)	172.58.83.106	Aldo Monroy	Limited Liability Company	201 Ne 44th St , Apt 111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Aldo Monroy	Aldogmonroy@gmail.com	Ankeny	Polk	IOWA	Aldo Monroy	Elizabeth lopez	Signed	(1) The employer does not elect the employers’ liability coverage.	Aldo Monroy	Aldogmonroy@gmail.com	Owner	Ankeny	Polk	IOWA	Aldo g monroy reyes	Elizabeth tavarez lopez	Signed
1724	2023-07-06 19:34	Anonymous (not verified)	94.188.207.223	ALDO B. CANCINO HERNANDEZ	Proprietorship	2524 SHADOW CREEK LN, DES MOINES, IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-06	ALDO B. CANCINO HERNANDEZ	aldo94.cansino@gmail.com	DES MOINES	USA	IOWA	JUAN M. MAYORGA	OFELIA BUSTILLOS VALENZUELA	Signed	(1) The employer does not elect the employers’ liability coverage.	ALDO B. CANCINO HERNANDEZ	aldo94.cancino@gmail.com	SELF	DES MOINES	USA	IOWA	JUAN M. MAYORGA	OFELIA BUSTILLOS VALENZUELA	Signed
487	2021-04-20 11:10	Anonymous (not verified)	207.191.193.167	Chento Construction	Proprietorship	702 Lincoln St. Ainsworth, IA 52201	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-05	Alberto Garcia	chentoconstruction@hotmail.com	Ainsworth	Washington	Iowa	Anthony Johnson	Jessica Lopez	Signed	(1) The employer does not elect the employers’ liability coverage.	Alberto Garcia	chentoconstruction@hotmail.com	Owner	Ainsworth	Washington	Iowa	Anthony Johnson	Jessica Lopez	Signed
1937	2023-12-04 17:42	Anonymous (not verified)	94.188.205.174	Albert Schwartz	Proprietorship	2250 Hwy 1 Sw Kalona, ia 52247	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-04	Albert Schwartz	sageburnner100@msn.com	Kalona	Johnson	Iowa	Laura Schwartz	Jackie Etheredge	Signed	(1) The employer does not elect the employers’ liability coverage.	Albert Schwartz	sageburnner100@msn.com	Myself	Kalona	Johnson	Iowa	Laura Schwartz	Jackie Etheredge	Signed
87	2020-03-11 15:42	Anonymous (not verified)	50.105.78.41	Al's Aerial Spraying, LLC	Limited Liability Company	3473 N Shepardsville Rd, Ovid MI 48866	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-11	Albert Edward Schiffer	Al400@aol.com	Ovid	Cliinton	Michigan	Seth Alexander	Nicholas Crofoot	Signed	(1) The employer does not elect the employers’ liability coverage.	Albert Edward Schiffer	Al400@aol.com	Boss	Ovid	Clinto	Michigan	Nicholas Crofoot	Nicholas Crofoot	Signed
765	2021-11-22 16:07	Anonymous (not verified)	63.229.189.35	Stahmer Construction	Proprietorship	318 Jackson St N Harris IA 51345	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-22	Alan Stahmer	abigail@rickmilesartisans.com	Harris	Osceola	Iowa	Abigail Miles	Alex Miles	Signed	(1) The employer does not elect the employers’ liability coverage.	Alan Stahmer	abigail@rickmilesartisans.com	Self	Harris	Osceola	Iowa	Abigail Miles	Alex Miles	Signed
1166	2022-06-23 09:44	Anonymous (not verified)	74.84.106.106	alan squires	Proprietorship	702 2nd ave sw #4	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-23	alan squires	shanesq411@gmail.comm	altoona	polk	iowa	TIna Owens	Rita Littell	Signed	(1) The employer does not elect the employers’ liability coverage.	alan squires	shanesq411@gmail.com	self	altoona	polk	iowa	Tina Owens	Rita Littell	Signed
2237	2024-05-23 12:51	Anonymous (not verified)	94.188.205.169	Lake Painting & Interiors, LLC	Limited Liability Company	403 E High St., New Sharon, IA 50207	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-23	Alan Kurtis Lake	alan@lakepaintingiowa.com	New Sharon	Mahaska	Iowa	Deb DeJong	Marcia Brown	Signed	(1) The employer does not elect the employers’ liability coverage.	Amber Lake	amber@lakepaintingiowa.com	Office Manager	New Sharon	Mahaska	Iowa	Deb DeJong	Marcia Brown	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
1456	2023-02-15 13:12	Anonymous (not verified)	94.188.205.168	Bloodgood construction services	Proprietorship	4422 happy trail prole ia 50229	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-15	Alan Dean bloodgood	alanbloodgood@gmail.com	Prole	Warren	Ia	Derek bloodgood	Albert bloodgood	Signed	(1) The employer does not elect the employers’ liability coverage.	Bloodgood construction services	alanbloodgood@gmail.com	Self	Prole	Warren	Ia	Derek bloodgood	Albert bloodgood	Signed

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