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:
1842	2023-09-14 14:08	Anonymous (not verified)	94.188.205.174	RM Construction	Limited Liability Company	1623 120th Street, Hazleton, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-14	Roy Miller	roymiller@aol.com	Hazleton	Buchanan	Iowa	Steve Frost	Julie Schick	Signed	(1) The employer does not elect the employers’ liability coverage.	Roy Miller	roymiller@aol.com	self	Hazleton	Buchanan	Iowa	Steve Frost	Julie Schick	Signed
1954	2023-12-13 13:51	Anonymous (not verified)	94.188.207.227	Beeson Trucking LLC	Limited Liability Company	219 Tilden St Kingsley IA 51028	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-13	Jeremy Beeson	jeremy4k78@yahoo.com	Kingsley	Plymouth	IA	Katherine Weaver	Darla Robley	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeremy Beeson	jeremy4k78@yahoo.com	Self	Kingsley	Plymouth	IA	Katherine Weaver	Darla Robley	Signed
100	2020-03-24 15:46	Anonymous (not verified)	216.51.130.87	Lake City Electric, LLC	Limited Liability Company	113 E Main Street, Lake City, IA 51449	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-24	Lonnie R. Daisy	lcelectric@iowatelecom.net	Lake City	Calhoun	IOWA	Sheryl Lynch	Karen Prebeck	Signed	(1) The employer does not elect the employers’ liability coverage.	Lonnie R. Daisy	lcelectric@iowatelecom.net	self	Lake City	Calhoun	IOWA	Sheryl Lynch	Karen Prebeck	Signed
2066	2024-02-29 15:27	Anonymous (not verified)	94.188.207.230	Julian Abey	Proprietorship	4405 NW Abilene Road, Ankeny IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-29	Julian Abey	Jabeyhpro@gmail.com	Ankeny	Polk	IA	Eric Ndifon	Peter Gara	Signed	(1) The employer does not elect the employers’ liability coverage.	Julian Abey	Jabeyhpro@gmail.com	Self	Ankeny	IA	IA	Eric Ndifon	Peter Gara	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
2178	2024-04-25 10:56	Anonymous (not verified)	94.188.205.176	Loonpa Landscaping LLC	Limited Liability Partnership	5309 Red Oak Ln Cedar Falls, IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2024-04-25	Daniel J White	danny@barerootslawn.care	Cedar Falls	Black Hawk	iowa	Kari White	James White	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Daniel J White	danny@barerootslawn.care	Owner	Cedar Falls	Black Hawk	Iowa	James White	Kari White	Signed
324	2020-11-20 09:08	Anonymous (not verified)	71.39.227.238	County-Line Construction, LLC	Limited Liability Company	314 NE 2nd St, Panora, IA 50216	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-11-20	John Steve Vogel	thevogels@netins.net	Panora	Guthrie	Iowa	Steve Phillips	Abbey Luellen	Signed	(1) The employer does not elect the employers’ liability coverage.	John Steve Vogel	thevogels@netins.net	Owner	Panora	Guthrie	Iowa	Steve Phillips	Abbey Luellen	Signed
883	2022-02-02 14:07	Anonymous (not verified)	104.201.67.178	Juan Monterde	Proprietorship	9235 Swanson Blvd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Juan Monterded	s.thomas@nationwideofficecare.com	Cedar Rapids	Linn	Iowa	Cory Shelton	Scott D Thomas	Signed	(1) The employer does not elect the employers’ liability coverage.	Scott D Thomas	scottthomascpa@msn.com	Consultant	West Des Moines	IA	United States	Rich Darr	Mari Lopez	Signed
436	2021-03-16 13:37	Anonymous (not verified)	141.193.221.33	Custom Applicationz	Partnership	13220 Hwy S70 Plano, IA 52581	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-16	Zebulun Joiner	joinerconst@gmail.com	Plano	Appanoose	IA	Danielle Joiner	Zebulun Joiner	Signed	(1) The employer does not elect the employers’ liability coverage.	Danielle Joiner	joinerconst@gmail.com	Self/Wife of Partner	Plano	Appanoose	IA	Zebulun Joiner	Danielle Joiner	Signed
995	2022-03-22 14:40	Anonymous (not verified)	50.82.130.211	Pietig Construction, LLC	Limited Liability Company	302 Brookside Dr, Parkersburg, IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-09	Joel Pietig	cmins_re@mchsi.com	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Joel Pietig	cmins_re@mchsi.com	Owner/Self	Parkersburg	Butler	IA	Chad Campbell	Roxanne Kolder	Signed
548	2021-06-24 22:08	Anonymous (not verified)	173.31.28.69	Brown's Window Cleaning +PLUS	Proprietorship	700 11th Ave NW	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-06-24	Lawrence Brown	brownswindowcleaningplus@gmail.com	Altoona	Iowa	United States	Jason Alderman	Colette Evans	Signed	(1) The employer does not elect the employers’ liability coverage.	Lawrence Brown	brownswindowcleaningplus@gmail.com	Self	Altoona	Iowa	United States	Jason Alderman	Colette Evans	Signed
1107	2022-05-16 15:28	Anonymous (not verified)	64.33.230.163	hangar 8 spray service	Limited Liability Company	1626 airport dr	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-16	jed douglas hansen	hangar.8@hotmail.com	Clark	South Dakota	United States	jed douglas hansen	jed douglas hansen	Signed	(1) The employer does not elect the employers’ liability coverage.	jed douglas hansen	hangar.8@hotmail.com	contract	Clark	South Dakota	United States	Jed Hansen	Jed Hansen	Signed
660	2021-09-30 14:15	Anonymous (not verified)	172.58.86.219	LeafFilter	Limited Liability Company	3060 SE Grimes Blvd. Suite 100-300, Grimes, IA 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-30	Mohammed Albayati	mmm2002faris@yahoo.com	West Des Moines	Polk	Iowa	Tammy Decker	Yaseen Albayati	Signed	(1) The employer does not elect the employers’ liability coverage.	Mohammed Albayati	albayatim28@gmail.com	Employee	Grimes	Polk	Iowa	Tammy Decker	Yaseen Albayati	Signed
1219	2022-07-21 12:39	Anonymous (not verified)	98.22.2.115	Keeling Services	Proprietorship	3190 SE 64th St, 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.	2022-07-21	Josh keeling	Joshuakeeling110@gmail.com	Pleasant Hill	Iowa	United States	Kali Keeling	Matthew Keeling	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Bond	mbond@leaffilter.com	Regional sales manager	Grimes	Polk	Iowa	Kali Keeling	Matthew Keeling	Signed
772	2021-11-23 10:13	Anonymous (not verified)	63.229.189.35	Hubbards Cupboards	Proprietorship	713 2nd Ave SW, Spencer, IA 51301-5603	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	James Hubbard	abigail@rickmilesartisans.com	Spencer	Clay	Iowa	Abigail Miles	Alex Miles	Signed	(1) The employer does not elect the employers’ liability coverage.	James Hubbard	abigail@rickmilesartisans.com	Self	Spencer	Clay	Iowa	Abigail Miles	Alex Miles	Signed
1331	2022-10-11 13:17	Anonymous (not verified)	174.216.2.52	Parceros Construction LLC	Limited Liability Company	2315 Landon Rd. Apt. 206 North Liberty, IA 52317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-11	Laura Garavito	ldanielagaravitog@gmail.com	North Liberty	Johnson	IA	Derek Davis	Cory Beesler	Signed	(1) The employer does not elect the employers’ liability coverage.	Laura Garavito	ldanielagaravitog@gmail.com	Owner	North Liberty	Johnson	IA	Derek Davis	Cory Beesler	Signed
1443	2023-02-07 10:05	Anonymous (not verified)	166.181.84.211	Leaf home solutions	Limited Liability Company	1595 Georgetown rd Hudson Ohio 44236	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-07	Dean Martells	dn.mardesconstruction@gmail.com	Laporte city	Benton	Ia	Jeromia wilson	Todd mcknees	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Yurko	byurko@leacome.com	Recruiter	Hudson	Summit	Ohio	Brian mako	Mat kaulig	Signed
1555	2023-04-05 08:03	Anonymous (not verified)	94.188.207.227	DK Motor Freight	Proprietorship	3621 Tyler Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-05	David Kirchner	dkirchner89@gmail.com	Hartley	Obrien	Iowa	Janna VanDonge	Chad Driesen	Signed	(1) The employer does not elect the employers’ liability coverage.	David Kirchner	dkirchner89@gmail.com	Self	Hartley	Iowa	United States	Janna VanDonge	Chad Driesen	Signed
1667	2023-05-29 22:31	Anonymous (not verified)	94.188.207.226	All J Acres	Limited Liability Company	13522 120th Ave, Ottumwa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-26	Jonathan Bunt	jonbunt@gmail.com	Ottumwa	Wapello	IA	James Williamson	James Ash	Signed	(1) The employer does not elect the employers’ liability coverage.	Jonathan Bunt	jonbunt@gmail.com	Self	Ottumwa	Wapello	IA	James Williamson	James Ash	Signed
1858	2023-10-03 13:29	Anonymous (not verified)	94.188.207.223	Quad city drywall Solutions LLC	Limited Liability Company	5804 n thornwood ave Davenport iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-03	Erivan Emmanuel Montalvo Delcompare	montalvobills6@gmail.com	Davenport	Scott	Iowa	Natalia Ann Montalvo	Juan Portela	Signed	(1) The employer does not elect the employers’ liability coverage.	Erivan Emmanuel Montalvo Delcompare	montalvobills6@gmail.com	Owner	Davenport	Scott	Iowa	Natalia Montalvo	Juan Portela	Signed
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
337	2020-12-11 21:56	Anonymous (not verified)	66.129.217.166	Tabora Perez Minerva	Proprietorship	4494 Taft Ave SE Trl. 1B Iowa City, IA 52240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-12-01	Tabora Perez Minerva	tonypauljohnson@yahoo.com	Iowa City	Johnson	Iowa	Anthony Johnson	Rafael Donis	Signed	(1) The employer does not elect the employers’ liability coverage.	Tabora Perez Minerva	tonypauljohnson@yahoo.com	Agent	Iowa City	Johnson	IA	Anthony Johnson	Rafael Donis	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
449	2021-03-25 10:53	Anonymous (not verified)	174.198.73.94	A&F Painting llc	Limited Liability Company	411 E Dunham 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.	2021-03-25	Miguel Afanador Olguin	mafanador02@gmail.com	Des Moines	Polk	Iowa	Alfonzo Afanador	Noemi Afanador	Signed	(1) The employer does not elect the employers’ liability coverage.	Miguel Afanador Olguin	mafanador02@gmail.com	Owner	Des Moines	Polk	Iowa	Alfonzo Alfanador	Noemi Alfanador	Signed
1008	2022-03-25 15:15	Anonymous (not verified)	174.192.130.230	Hill's Rehab &Landscape L.L.C	Limited Liability Company	3717 15th ave Moline Illinois 61365	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-25	Joshua hill	joshuajameshill79@gmail.com	Moline	Rock Island	Illinois	Lindsay erin Hill	NICOLE ann lear	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua james hill	joshuajameshill79@gmail.com	President	Moline	Rock Island	Illinois	Lindsay Erin Hill	NIcole ann lear	Signed
561	2021-07-08 09:11	Anonymous (not verified)	66.188.136.150	Aaron Maldonado dba ATM Trucking	Proprietorship	1011 Reynolds Drive, Charleston, IL 61920	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Aaron Maldonado dba ATM Trucking	kschumacher@tricorinsurance.com	Charleston	Coles	IL	Mitch Kemp	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Aaron Maldonado dba ATM Trucking	kschumacher@tricorinsurance.com	Same	Charleston	Coles	IL	Mitch Kemp	Shuree Behr	Signed
1120	2022-05-19 09:49	Anonymous (not verified)	65.125.92.130	JG Landscaping, LLC	Limited Liability Company	317 E 23rd St. Des Moines, IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-19	Javier Alexander Guzman	alexguz76@outlook.com	Des Moines	Polk	IA	Brenda Reedy	Chad Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Javier Alexander Guzman	alexguz76@outlook.com	Self	Des Moines	Polk	IA	Brenda Reedy	Chad Smith	Signed
673	2021-10-14 07:15	Anonymous (not verified)	97.125.239.203	Complete tile llc	Limited Liability Company	875 se gateway drive #311	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-14	Nedzad mustafic	completetile1@gmail.com	Grimes	Usa	Iowa	Enesa Mustafic	Edina avdic	Signed	(1) The employer does not elect the employers’ liability coverage.	Nedzad Mustafic	completetile1@gmail.com	Owner	Grimes	Usa	Iowa	Enesa mustafic	Edina avdic	Signed
1232	2022-07-28 18:27	Anonymous (not verified)	50.83.189.149	Eagle Construction Co LLC	Limited Liability Company	1150 county line rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-28	Carlos Flores	eagleconstruciontco.865@gmail.com	Des Moines	Warren	Iowa	Morgan Conrard	Ronika Htu	Signed	(1) The employer does not elect the employers’ liability coverage.	Carlos Flores	eagleconstruciontco.865@gmail.com	Owner	Des Moines	Warren	IA	Morgan Conrard	Ronika Htu	Signed
785	2021-12-09 09:15	Anonymous (not verified)	174.198.75.71	Daniel Vega camacho	Proprietorship	2415 river ,meadows drive Des Moines Iowa 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-09	Daniel Vega camacho	dvega50265@gmail.com	Des Moines	Polk	Iowa	Chad Smith	Adam Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Vega camacho	dvega50265@gmail.com	Self	Des Moines	Polk	Iowa	Chad Smith	Adam Smith	Signed
1344	2022-10-25 13:09	Anonymous (not verified)	69.76.241.21	Tom Cole	Proprietorship	742 Mill St. Council, IA 51503	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-25	Tom Cole	tcoleg1963@gmail.com	Council Bluffs, IA	Pottawattamie County, IA	Iowa	Jordan Nisiewicz	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Regional Recruiter	Kansas City, MO	Clay	Missouri	Jordan Nisiewicz	Jordan Loyd	Signed
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
1568	2023-04-12 10:46	Anonymous (not verified)	94.188.205.175	Daniel gramowski	Limited Liability Company	2835 raccoon street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-12	Daniel gramowski	oneanddoneroofing@gmail.com	Des moines	Polk	Iowa	Paige gramowski	Cole smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel gramowski	oneanddoneroofing@gmail.com	Owner	Des Moines	Polk	Iowa	Cole smith	Paige gramowski	Signed
1680	2023-06-06 12:08	Anonymous (not verified)	94.188.205.168	Sipac Drywall	Proprietorship	1130 Columbia St, Waterloo, IA 50703	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-06	Jennifer Sipac	jenniferyoung164@gmail.com	Waterloo	Black Hawk	Iowa	Augie Ferguson	Wendy Phillips	Signed	(1) The employer does not elect the employers’ liability coverage.	Jennifer Sipac	jenniferyoung164@gmail.com	Owner	Waterloo	Black Hawk	Iowa	Augie Ferguson	Wendy Phillips	Signed
1871	2023-10-18 10:27	Anonymous (not verified)	94.188.205.169	Derik Gonyier	Proprietorship	1421 Chicago Ave, Savanna, IL 61074	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-14	Derik Ray Gonyier	deriknalexis121413@gmail.com	Savanna	Carroll	IL	Kyle Lee Sturtz	Daryl Gonyier	Signed	(1) The employer does not elect the employers’ liability coverage.	Derik Ray Gonyier	deriknalexis121413@gmail.com	Self	Savanna	Carroll	IL	Kylee Lee	Daryl Eugene Gonyier	Signed
17	2019-12-31 09:24	Anonymous (not verified)	72.35.186.80	Grgurich Dozing & Tiling, LLC	Partnership	PO Box 131, Williamson, IA 50272	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Seth Grgurich	mcbroomt15@gmail.com	Williamson	Lucas	Iowa	Eric Curran	Stacy Smyser	Signed	(1) The employer does not elect the employers’ liability coverage.	Seth Grgurich	mcbroomt15@gmail.com	Partner	Williamson	Lucas	Iowa	Eric Curran	Stacy Smyser	Signed
1983	2024-01-11 13:02	Anonymous (not verified)	94.188.205.168	r&k propety solutions	Proprietorship	po box 53 cedar rapids iowa 52406	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-11	roy rohwedder	rohwedder.roy@yahoo.com	Cedar Rapids	linn	ia	Brian Ashlock	tim vaske	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Ashlock	brian@tricounty-iowa.com	General Manager	Center Point	Benton	ia	Tim Vaske	Roy Rohwedder	Signed
129	2020-04-24 15:28	Anonymous (not verified)	173.28.28.57	Michael Jansen	Proprietorship	108 6th Street, Parkersburg, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-10	Michael G Jansen	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael G Jansen	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
2095	2024-03-14 11:39	Anonymous (not verified)	205.221.255.62	Trimble Lawncare And Landscaping	Proprietorship	215 Boundary Ave Middletown IA 52638	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-14	Kevin Blake Trimble	rknhtrimble@yahoo.com	Middletown	Des Moines	Iowa	Katelyn Orth	Shayla Taeger	Signed	(1) The employer does not elect the employers’ liability coverage.	Kevin Blake Trimble	rknhtrimble@yahoo.com	owner	Middletown	Des Moines	Iowa	Katelyn Orth	Shayla Taeger	Signed
241	2020-08-23 16:10	Anonymous (not verified)	67.45.96.12	Wellik & Sons, LLC	Limited Liability Company	1770 HWY 18, Garner, IA 50438	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-23	Jason Yon Juenger	j420money@yahoo.com	Garner	Hancock	Iowa	Joshua P Wellik	Ashley S Wellik	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua Paul Wellik	wellikandsons@gmail.com	subcontractor	Garner	Hancock	Iowa	Joshua Paul Wellik	Ashley S Wellik	Signed
2207	2024-05-07 09:44	Anonymous (not verified)	94.188.207.226	Rodrimart brothers corp	Limited Liability Company	958 8th ave nw Altoona 50009	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-07	Enrique Rodriguez	carluto_1983@hotmail.com	Altoona	Polk	Iowa	Adan boge	Lonce wester	Signed	(1) The employer does not elect the employers’ liability coverage.	Enrique Rodriguez	carluto_1983@hotmail.com	President	Altoona	Polk	Iowa	Adan boge	Leans wester	Signed
353	2021-01-11 14:38	Anonymous (not verified)	66.188.136.150	Igor Curguz	Proprietorship	927 1/2 W Grand 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.	2021-01-11	Igor Curguz	kschumacher@tricorinsurance.com	Beloit	Rock	WI	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	Igor Curguz	kschumacher@tricorinsurance.com	Same	Beloit	Rock	WI	Russell Masartis	Nancy Wortley	Signed
912	2022-02-14 17:51	Anonymous (not verified)	72.168.160.122	Mark Weiss	Proprietorship	11461 NW Timber Way Granger Iowa 50109	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-14	Mark Weiss	kkweiss77@yahoo.com	Granger	Polk	Iowa	Paul Ness	Deb Ness	Signed	(1) The employer does not elect the employers’ liability coverage.	Casi Sparks	csparks@destinyhomesusa.com	Subcontractor	Waukee	Dallas	Iowa	Paul Ness	Deb Ness	Signed
465	2021-04-07 22:24	Anonymous (not verified)	173.18.251.105	TEMPLEMAN LAWN CARE	Proprietorship	1612 Lomas Cr.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-11-01	Tim Lee Templemn	nancytempleman@gmail.com	Atlantic	Iowa	United States	Tara Jessen	Alfred Wede	Signed	(1) The employer does not elect the employers’ liability coverage.	Tim Lee Templeman	nancytempleman@gmail.com	self	Atlantic	Iowa	Iowa	Tara Jessen	Alfred Wede	Signed
1024	2022-04-01 09:25	Anonymous (not verified)	173.23.251.188	Norwalk Exterior Home Improvement	Proprietorship	6391 Grimes St 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.	2022-04-01	John Lester	norwalkexterior@gmail.com	Indianola	Warren	Iowa	Tara Murphy	Mike Ryerson	Signed	(1) The employer does not elect the employers’ liability coverage.	John Lester	norwalkexterior@gmail.com	owner	Indianola	Warren	Iowa	Tara Murphy	Mike Ryerson	Signed
577	2021-07-16 13:45	Anonymous (not verified)	204.155.61.217	Chris & Michele Burke dba Studio Dance	Proprietorship	3907 Center Point Rd NE, Cedar Rapids, IA 52402	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-07-16	Michele Burke	michele@studiodanceia.com	Marion	Linn	Iowa	Molly Feldman	Sharon Naber	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Michele Burke	michele@studiodanceia.com	owner	Marion	Linn	Iowa	Molly Feldman	Sharon Naber	Signed
1136	2022-05-31 13:46	Anonymous (not verified)	173.31.148.43	OKOBOJI BURRITO COMPANY LLC	Limited Liability Company	39502 710TH ST LAKEFIELD, MN 56105	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-26	KATHRYN SCHULTZ	kathrynlucier@ymail.com	LAKEFIELD	JACKSON	MN	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	KATHRYN SCHULTZ	kathrynlucier@ymail.com	SELF	LAKEFIELD	JACKSON	MN	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
689	2021-10-25 14:38	Anonymous (not verified)	107.197.114.249	Brookstin Flooring LLC	Limited Liability Company	1702 Brown Deer Rd Coralville IA 52241	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-10-25	Richard T Klemesrud	rickklemesrud@gmail.com	CORALVILLE	IA	United States	Brian Woods	Sherry Woods	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Richard T Klemesrud	rickklemesrud@gmail.com	Myself / Owner	CORALVILLE	IA	United States	Brian Woods	Sherry Woods	Signed
1248	2022-08-09 11:29	Anonymous (not verified)	166.181.82.131	Kelly Kellogg	Proprietorship	1305 N 1st st apt 16	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-09	Kelly	Kkell0223@gmail.com	Indianola	Warren	Iowa	Kelly Kellogg	Amy Kellogg	Signed	(1) The employer does not elect the employers’ liability coverage.	Royal flooring	workorders@shoproyalflooring.com	Employee	Urbandale	Polk	Iowa	Amy	Kelly	Signed
801	2021-12-16 21:35	Anonymous (not verified)	98.21.205.195	Kustom Home Improvements	Proprietorship	400 Davidson st new Virginia Iowa 50210	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-16	David Jack Kimmel	kustomhomeimprovements.dk@gmail.com	New Virginia	Warren	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed	(1) The employer does not elect the employers’ liability coverage.	David Jack Kimmel	kustomhomeimprovements.dk@gmail.com	Self	New Virginia	Warren	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed

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