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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:
1480 2023-02-24 08:54 Anonymous (not verified) 94.188.205.176 Shear Texture Limited Liability Company 2000 Wiley Blvd SW I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-24 Wendy Kiser kiser187@msn.com Cedar Rapids Linn Iowa Kim Erickson Shauna Whitaker Signed (1) The employer does not elect the employers’ liability coverage. Wendy Kiser kiser187@msn.com Self Cedar Rapids Linn Iowa Kim Erickson Shauna Whitaker Signed
1479 2023-02-24 08:34 Anonymous (not verified) 94.188.207.229 Sedenka Excavating and Habitat Limited Liability Partnership 204 Meadowview Drive, Lisbon, IA 52253 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-24 Trey Sedenka SedenkaEH@gmail.com Lisbon Cedar Iowa Robert Cummings Jayson Wallace Signed (1) The employer does not elect the employers’ liability coverage. Trey Sedenka SedenkaEH@gmail.com Owner Lisbon Cedar Iowa Robert Cummings Jayson Wallace Signed
1478 2023-02-23 13:25 Anonymous (not verified) 94.188.207.230 Achenbach Renovations and Flooring Proprietorship PO Box 234 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-23 Michael Achenbach constructiowa.ma@gmail.com Adair Iowa United States Michael Achenbach Michael Achenbach Signed (1) The employer does not elect the employers’ liability coverage. Michael Achenbach constructiowa.ma@gmail.com Owner Adair Iowa United States Michael Achenbach Michael Achenbach Signed
1477 2023-02-23 11:45 Anonymous (not verified) 94.188.205.166 Earl Woods DBA Solar Solutions Proprietorship 1328 42nd St Des Moines IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-23 Earl Woods solarsolutions_1@msn.com Des Moines Polk Iowa Terrie Woods Tracy Day Signed (1) The employer does not elect the employers’ liability coverage. Earl Woods solarsolutions_1@msn.com wife Des Moines Polk IA Terrie Woods Tracy Day Signed
1476 2023-02-22 12:23 Anonymous (not verified) 94.188.205.174 KARL INGWERSEN Proprietorship 2716 FRANCIS SITES 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. 2023-02-22 KARL INGWERSEN KARL58INGWERSEN@GMAIL.COM SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. KARL INGWERSEN KARL58INGWERSEN@GMAIL.COM SELF SPIRIT LAKE DICKSINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1475 2023-02-21 18:42 Anonymous (not verified) 94.188.207.230 Michael Goodyk Consgtruction Proprietorship 2392 Keokuk Drive Pella, Iowa. 50219 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-20 Michael Jay Goodyk mikegoodyk@gmail.com Pella Marion Iowa Joy Ekloffe Rick Ekloffe Signed (1) The employer does not elect the employers’ liability coverage. Gorp Edwards insurance bwilliams@vangorpins.com Insurance Agent Pella Marion Iowa Joy Ekloffe Rick Ekloffe Signed
1474 2023-02-20 19:48 Anonymous (not verified) 94.188.207.230 Individual entity Proprietorship 801 CELTIC DR, Waukee IA 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-20 Gerardo Castro jackiecastro18@gmail.com Waukee IA United States Jackelin Castro Esmeralda Castro Signed (1) The employer does not elect the employers’ liability coverage. Gerardo Castro jackiecastro18@gmail.com self Waukee Dallas Iowa Jackelin Castro Esmeralda Castro 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
1472 2023-02-20 15:52 Anonymous (not verified) 94.188.207.230 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 Curtis Fox sales@foxfarmsllc.com Orchard IOWA United States Darrel Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Curtis Fox sales@foxfarmsllc.com Self Orchard IOWA United States Darrel Elsbernd Chris Fye Signed
1471 2023-02-20 10:24 Anonymous (not verified) 94.188.205.169 Vega Investments Limited Liability Company 330 NE 72nd Street, Pleasant Hill, IA 50327 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-20 Stephanie Westrom stephanie.westrom@microsoft.com Pleasant Hill Polk Iowa Thomas Westrom Jean Schnake Signed (1) The employer does not elect the employers’ liability coverage. Stephanie Westrom stephanie.westrom@microsoft.com Owner Pleasant Hill Polk Iowa Thomas Westrom Jean Schnake Signed
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
1469 2023-02-19 18:23 Anonymous (not verified) 94.188.205.169 Superior Sheet Metal LLC Limited Liability Company 1819 MM Ave Marengo, IA 52301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-19 Adam Lynn Nielsen adamnielsen4@yahoo.com Marengo Iowa United States Emily Jean Nielsen Joseph Daryl Kriegel Signed (1) The employer does not elect the employers’ liability coverage. Adam Lynn Nielsen adamnielsen4@yahoo.com Self Marengo Iowa Iowa Emily Jean Nielsen Joseph Daryl Kriegel Signed
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
1467 2023-02-17 16:14 Anonymous (not verified) 94.188.205.169 H & C Construction Limited Liability Company 708 Vine Street Lucas IA 50151 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Colton Charles Clarke ccclarke95@gmail.com Truro IA United States Hailey Sullivan Shelby Comer Signed (1) The employer does not elect the employers’ liability coverage. H & C Construction ccclarke95@gmail.com Manager Truro IA United States Hailey Sullivan Shelby Comer Signed
1466 2023-02-17 15:12 Anonymous (not verified) 94.188.207.230 BIG Roofing, LLC Limited Liability Company 5751 NE 22nd St. #304 Des Moines, IA 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-17 Tyler Jeffrey Baugh tj@bigroofing515.com Lincoln Lancaster Nebraska Steven Bieghler Andrew John Kohles Signed (1) The employer does not elect the employers’ liability coverage. Steven Craig Bieghler steve@bigroofing515.com Owner Cumming Dallas Iowa Tyler Jeffrey Baugh Andrew John Kohles Signed
1465 2023-02-17 15:05 Anonymous (not verified) 94.188.207.228 Big roofing Proprietorship 114 sw 58th dr I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-17 David Christiansen Mattc@bigroofing515.com Des moines Polk IA STEVE BIEGHLER Jordan walkup Signed (1) The employer does not elect the employers’ liability coverage. Matt christiansen Mattc@bigroofing515.com Self Des moines County Ia Steve bieghler Jordan walkup Signed
1464 2023-02-17 15:05 Anonymous (not verified) 94.188.205.166 Jordan Walkup Proprietorship 5751 NE 22nd St Des Moines IA 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-17 Jordan Walkup jordanw@bigroofing515.com Windsor Heights Polk IA Sarah Walkup Steve Bieghler Signed (1) The employer does not elect the employers’ liability coverage. Jordan Walkup jordanw@bigroofing515.com Self Windsor Heights Polk IA Sarah Walkup Steve Bieghler Signed
1463 2023-02-17 14:24 Anonymous (not verified) 94.188.207.224 Matt Evans Limited Liability Company 508 53rd Place West Des Moines, IA 50266 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-17 Matthew Evans matt@bigroofing515.com West Des Moines Polk Iowa Steve Bieghler Matt Evans Signed (1) The employer does not elect the employers’ liability coverage. Matthew Evans matt@bigroofing515.com Self West Des Moines Polk Iowa Steve Bieghler Matt Evans Signed
1462 2023-02-17 13:45 Anonymous (not verified) 94.188.207.227 Med Spa Institute of America, Dubuque LLC Limited Liability Partnership 3337 Hillcrest Rd - Dubuque, IA 52002 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-11 Kaylee Webb jheims@english-insurance.com Dubuque Dubuque United States Joyce Heims Derrick Parsons Signed (1) The employer does not elect the employers’ liability coverage. Joyce Heims jheims@english-insurance.com self Dyersville IA United States Joyce Heims Derrick Parsons 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
1460 2023-02-16 12:36 Anonymous (not verified) 94.188.205.174 Certified Septic Service Proprietorship 2121 Rodeo ave monroe iowa 50170 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-16 Justin Rozendaal jusroz12@gmail.com Monroe Jasper Iowa Justin Rozendaal Miranda Rozendaal Signed (1) The employer does not elect the employers’ liability coverage. Justin Rozendaal certifiedseptic@gmail.com Self Monroe Jasper Iowa Justin Rozendaal Miranda Rozendaal Signed
1459 2023-02-16 09:07 Anonymous (not verified) 94.188.205.166 Lakerats Limited Liability Company 112 W Court Winterset IA 50273 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-05 Kyra Moore kyra@novushomemortgage.com Urbandale Polk Iowa Jessica Anderson Easton Anderson Signed (1) The employer does not elect the employers’ liability coverage. Kyra Moore kyra@novushomemortgage.com Owner Urbandale Polk Iowa Jessica Anderson Easton Anderson Signed
1458 2023-02-16 07:20 Anonymous (not verified) 94.188.205.167 Windsor Earth Works, dba Wells Commercial Flooring Limited Liability Company 1442 73rd Street, Windsor Heights, Ia. 50324 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-16 Timothy E Wells wellsba1@msn.com Windsor Heights Polk Iowa Leonard Klug Barbara Wells Signed (1) The employer does not elect the employers’ liability coverage. Barbara Wells wellsba65@gmail.com Spouse Windsor Heights Polk Iowa Leonard Klug Timothy Wells Signed
1457 2023-02-15 18:06 Anonymous (not verified) 94.188.205.166 Chad Cowan Limited Liability Company 2108 Locust St West Des Moines IA 50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-15 Chad Stuart Cowan chad@bigroofing515.com West Des Moines Polk Iowa Paul Mouw Rob Schultz Signed (1) The employer does not elect the employers’ liability coverage. Chad Cowan rr2cw@yahoo.com Same West Des Moines IA United States Paul Mouw Rob Schultz Signed
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
1455 2023-02-15 11:44 Anonymous (not verified) 94.188.205.177 Bruce A. Nelson Proprietorship 300 Shetland Dr Nw Cedar Rapids, IA 52405 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-15 Bruce A. Nelson sherylnelson15@yahoo.com Cedar Rapids Linn Iowa Lynn M Haigh David Reibsamen Signed (1) The employer does not elect the employers’ liability coverage. Sheryl Nelson sherylnelson15@yahoo.com Wife Cedar Rapids Linn Iowa Lynn M. Haigh David Reibsamen Signed
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
1453 2023-02-14 07:19 Anonymous (not verified) 94.188.207.230 Milton Gray Proprietorship 255 10th Ave., Marion, IA 52302, US I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-13 Milton Gray miltongray23@gmail.com Marion, IA Linn Iowa Jordan Nisiewicz Charles Wood Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay MO Charles Wood Steven Geisler Signed
1452 2023-02-13 16:49 Anonymous (not verified) 94.188.207.228 The Wine Shop, LLC Limited Liability Company 305 Main St, Cedar Falls, IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2023-02-13 Dana Swasand danaswasand@rocketmail.com Steamboat Rock Hardin Co. Iowa Jay Schares Nicole Erickson Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Dana Swasand danaswasand@rocketmail.com Owner/Member Steamboat Rock Hardin Co. Iowa Jay Schares Nicole Erickson Signed
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
1450 2023-02-11 10:59 Anonymous (not verified) 94.188.205.168 JOSE G OLIVAREZ Limited Liability Company 1529 11TH ST DES MOINES IA 50314 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-11 JOSE G OLIVAREZ joseolivares742@gmail.com DES MOINES POLK IOWA SAMIR RAHMANOVIC SAMIR RAHMANOVIC Signed (1) The employer does not elect the employers’ liability coverage. none joseolivares742@gmail.com none DES MOINES POLK IOWA samir rahmanovic samir rahmanovic Signed
1449 2023-02-11 10:37 Anonymous (not verified) 94.188.207.227 Luxury Home Improvements Limited Liability Company 4117 Boyd st Des Moines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-11 Luis A Hernandez luxuryhomes.iowa@gmail.com Des Moines Polk Iowa Maria T Lopez Josmar Hernandez Signed (1) The employer does not elect the employers’ liability coverage. Luis A Hernandez luxuryhomes.iowa@gmail.com Self Des Moines Polk Iowa Maria T Lopez Josmar Hernandez Signed
1448 2023-02-10 16:55 Anonymous (not verified) 94.188.205.177 Marks Nursery LLC Limited Liability Company 15008 310th Trl, Redfield, IA 50233 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-10 Susan L Jones sljoines026@gmail.com Redfield Dallas Iowa Douglas Jones Caitlin Zimmerman Signed (1) The employer does not elect the employers’ liability coverage. Donald Richardson DonR@phillipsassociatesins.net Agent Redfield Dallas Iowa Douglas Zimmerman Caitlin Zimmerman Signed
1447 2023-02-09 16:12 Anonymous (not verified) 94.188.205.166 Ryan Klocke Limited Liability Company 315 1st Street Templeton, IA 54163 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-09 Ryan Klocke heidi@nextgenagsupply.com Templeton Carroll Iowa Kim Gienau Zach Counsell Signed (1) The employer does not elect the employers’ liability coverage. Ryan Klocke heidi@nexgenagsupply.com President Templeton Carroll Iowa Kim Gienau Zach Counsell Signed
1446 2023-02-08 16:49 Anonymous (not verified) 94.188.207.228 ZAHID ALI Limited Liability Company 3245 SOUTHGATE PL SW, IOWA 52404 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-10 ZAHID ALI ali@americaninncid.com CEDAR RAPIDS USA IOWA ZAHID ALI ZAHID ALI Signed (1) The employer does not elect the employers’ liability coverage. ZAHID ALI ali@americaninncid.com self cedar rapids usa iowa ZAHID ALI ZAHID ALI Signed
1445 2023-02-08 14:56 Anonymous (not verified) 94.188.207.225 Spencer Imaging Center, LLC Limited Liability Company 710 S. 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. 2023-02-08 William Jay Muller mullerwilliam@hotmail.com Spencer Clay IA Shanna Marie Kooker Chad A Roemeling Signed (1) The employer does not elect the employers’ liability coverage. Alexander Pruitt apruitt@ncn.net Partner Spencer Clay IA Shanna Marie Kooker Chad A Roemeling Signed
1444 2023-02-07 14:57 Anonymous (not verified) 173.21.126.4 Rhino Roofing Limited Liability Company 2534 Garfield AVE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-07 Irwins Martinez rhinoroofingsiding21@gmail.com Des Moines Polk Iowa Sara Titus Justin Williams Signed (1) The employer does not elect the employers’ liability coverage. Irwin Martinez rhinoroofing21@gmail.com Self Des Moines Polk Iowa Sara Titus Justin Williams Signed
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
1442 2023-02-06 14:40 Anonymous (not verified) 69.40.94.166 ESW CONSTRUCTION INC Partnership 315 hIGHWAY 22, KESWICK IA 50136 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-06 WENDELL WILEY rtsieren@gmail.com BLOOMFIED DAVIS IOWA JULIE WHITE REBECCA APPLEGET Signed (1) The employer does not elect the employers’ liability coverage. BARBARA EDMUNDSON barb@iowacropservice.com agent SIGOURNEY KEOKUK IOWA JULIE WHITE REBECCA APPLEGET Signed
1441 2023-02-06 14:37 Anonymous (not verified) 69.40.94.166 ESW CONSTRUCTION INC Partnership 35 HIGHWAY 22, KESWICK IA 50136 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-06 JOSHUA EDMUNDSON payten@iowacropservice.com KESWICK KEOKUK IOWA JULIE WHITE REBECCA APPLEGET Signed (1) The employer does not elect the employers’ liability coverage. BARBARA EDMUNDSON barb@iowacropservice.com agent SIGOURNEY KEOKUK IOWA JULIE WHITE REBECCA APPLEGET Signed
1440 2023-02-06 14:24 Anonymous (not verified) 69.40.94.166 ESW CONSTRUCTION INC Partnership 315 hIGHWAY 22, KESWICK IA 50136 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-06 ROSS SIEREN rtsieren@gmail.com KESWICK KEOKUK IOWA JULIE WHITE REBECCA APPLEGET Signed (1) The employer does not elect the employers’ liability coverage. BARBARA EDMUNDSON barb@iowacropservice.com agent SIGOURNEY KEOKUK IOWA JULIE WHITE REBECCA APPLEGET Signed
1439 2023-02-06 11:00 Anonymous (not verified) 96.31.1.206 L&C LLC Limited Liability Company 615 W 6TH ST 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. 2023-02-06 CARLOS MEDINA joel@walkerinsuranceia.com Estherville EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. CARLOS MEDINA joel@walkerinsuranceia.com SELF Estherville EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1438 2023-02-03 14:23 Anonymous (not verified) 173.18.22.217 Cruz Construction Company, LLC Proprietorship 2105 Clark Street, Des Moines, IA 50311 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-03 Juan Canseco Cruz jcruz2515@icloud.com Des Moines Polk Iowa Erick Schuldt Kelly Coluzzi Signed (1) The employer does not elect the employers’ liability coverage. Juan Conseco Cruz jcruz2515@icloud.com Owner Des Moines Polk Iowa Erick Schuldt Kelly Coluzzi Signed
1437 2023-02-01 15:42 Anonymous (not verified) 174.215.242.112 Safe step walk in tub of Minnesota Limited Liability Company 7300 Washington Ave S. Eden prairie, MN 55344 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-01 Edward Koch etkdbq@aol.com Waterloo IA United States Glenda mclarty Coen Koch Signed (1) The employer does not elect the employers’ liability coverage. James alley JAlley@safesteptub.com Vice president of production Eden prairie Hennepin MN Brent Jarvis Bruce illies Signed
1436 2023-02-01 11:53 Anonymous (not verified) 174.215.242.112 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. 2023-02-01 Edward Koch etkdbq@aol.com Waterloo IA United States Glenda mclarty Coen Koch Signed (1) The employer does not elect the employers’ liability coverage. Brian yurko byurko@leafhome.com Recruiter Hudson Summit Ohio Brian Mako Matt kaulig Signed
1435 2023-01-31 14:33 Anonymous (not verified) 174.215.242.112 Premier builders Proprietorship 1821 East Ridgeway I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-31 Edward Koch etkdbq@aol.com Waterloo IA United States Glenda mclarty Coen Koch Signed (1) The employer does not elect the employers’ liability coverage. Edward Koch etkdbq@aol.com Owner Waterloo IA United States Glenda Mclarty Coen Koch Signed
1434 2023-01-31 07:12 Anonymous (not verified) 162.233.75.173 abc Proprietorship 1122 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-31 Brian Yurko byurko714@gmail.com Cedar Falls Black Hawk Iowa pete re pete Signed (1) The employer does not elect the employers’ liability coverage. LHE byurko@leafhome.com contractor Deerfield Beach Florida United States pete re pete Signed
1433 2023-01-27 13:24 Anonymous (not verified) 184.97.152.214 Rwdcarpet Proprietorship 4927 cedarbrook drive I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-27 Robert Wayne Durand iii rwdcarpet24@gmail.com Council bluffs Pottawattamie Iowa Kitty whissinand Kelley durand Signed (1) The employer does not elect the employers’ liability coverage. Robert Wayne Durand iii rwdcarpet24@gmail.com Self Council bluffs Pottawattamie Iowa Kitty whissinand Kelley Durand Signed
1432 2023-01-25 16:52 Anonymous (not verified) 174.228.33.48 Thermal Tight Insulators Proprietorship 1331 Linden 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. 2023-01-25 Shawn Carter steelershawn@gmail.com Harlan Iowa United States Barbara Carter McKenzie carter Signed (1) The employer does not elect the employers’ liability coverage. Shawn Carter steelershawn@gmail.com Self Harlan Iowa United States Barbara Carter McKenzie carter Signed
1431 2023-01-25 16:24 Anonymous (not verified) 172.56.249.51 Warren transport Limited Liability Company 3124 titan trail Waterloo,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. 2023-01-25 Lamarcaus Lunford universalvoyager1@gmail.com Elkhart IN Indiana Quinetta shead Eric fikes Signed (1) The employer does not elect the employers’ liability coverage. Lamarcaus Lunford universalvoyager1@gmail.com Owner Elkhart IN Indiana Quinetta shead Eric fikes Signed