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:
925	2022-02-17 13:07	Anonymous (not verified)	208.81.192.69	Wapsie Valley Construction, LLC	Limited Liability Company	1154 Dennison Ave., Fairbank, IA 50629	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-17	Chester H. Borntrager	accounting@robertseddy.com	Hazleton	Buchanan	Iowa	Brian C. Eddy	Samantha J. Stelter	Signed	(1) The employer does not elect the employers’ liability coverage.	Merle Miller	accounting@robertseddy.com	Same person	Fairbank	Buchanan	Iowa	Brian C. Eddy	Samantha J. Stelter	Signed
2021	2024-02-02 10:12	Anonymous (not verified)	94.188.207.227	JUSIC ENTERPRISES LLC DBA MJS TREE SERVICE	Limited Liability Company	11619 NW 106TH AVE GRANGER, IA 50109	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-02	MERSUDIN JUSIC	MERSO.JUSIC@GMAIL.COM	GRANGER	POLK COUNTY	IOWA	RICHARD BALES	ZACHARY SMITH	Signed	(1) The employer does not elect the employers’ liability coverage.	MERSUDIN JUSIC	MERSO.JUSIC@GMAIL.COM	MEMBER OWNER	GRANGER	POLK	IOWA	RICH BALES	ZACHARY SMITH	Signed
1895	2023-11-03 12:21	Anonymous (not verified)	94.188.207.227	Oxbo LLC	Limited Liability Company	2528 Evergreen Ave. Red Oak, IA 51566	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-03	Mettra Sperling	sperlingrose66@gmail.com	Red Oak	Montgomery	IA	Chantal Sperling	Derek Penry	Signed	(1) The employer does not elect the employers’ liability coverage.	Mettra Sperling	sperlingrose66@gmail.com	Self	Red Oak	Montgomery	IA	Chantal Sperling	Derek Penry	Signed
1926	2023-11-29 10:45	Anonymous (not verified)	94.188.207.224	M&M Janitorial LLC	Limited Liability Company	243 28th St Dr SE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-29	Mackenzie Willits	mackenziewillits@gmail.com	Cedar Rapids	Linn	United States	Fransisco ruiz	Alexander ruiz	Signed	(1) The employer does not elect the employers’ liability coverage.	Meyling willits	mackenziewillits@gmail.com	Owner	cedar rapids	Linn	United States	Alexander ruiz	Francisco ruiz	Signed
1835	2023-09-09 15:11	Anonymous (not verified)	94.188.207.224	Heartland Ultrasonography Group	Limited Liability Company	1015 Woodland Dr Carlisle, IA 50047	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-09	Micah Ezra Wiele	mewiele99@gmail.com	Ankeny	Polk	Iowa	Nathan Miguel Diaz	Brandon Allen Pemoulie	Signed	(1) The employer does not elect the employers’ liability coverage.	Micah Ezra Wiele	heartlandusgroup@outlook.com	Co-owner	Ankeny	Polk	Iowa	Nathan Miguel Diaz	Brandon Allen Pemoulie	Signed
846	2022-01-20 12:02	Anonymous (not verified)	97.107.199.129	Moval Motors LLC	Limited Liability Company	3153 Joliet Ave Missouri Valley IA 51555	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-19	Michael Porter	msporter8855@hotmail.com	Papillion	sarpy	Nebraska	Jon Paul Burton	Scott Porter	Signed	(1) The employer does not elect the employers’ liability coverage.	Micahel Porter	mporter8855@hotmail.com	secretary of Moval	Papillion	Sarpy	Nebraska	Jon Paul Bruton	Scott Porter	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
626	2021-08-31 11:39	Anonymous (not verified)	166.181.81.253	Birds landscape maintenance LLC	Limited Liability Company	1307 w 4th st south	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-31	Michael Alan bird	birdslawn@hotmail.com	Newton	Jasper	Iowa	Jeff Dennis carder	Dustin James bos	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Alan bird	birdslawn@hotmail.com	Same - owner	Newton	Jasper	Iowa	Jeff Dennis carder	Dustin James bos	Signed
863	2022-01-27 12:13	Anonymous (not verified)	174.198.81.166	Big Bear Construction llc	Limited Liability Company	4508 Hiawatha Ave ne Cedar Rapids iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-27	Kevin Paul Becker jr	kbeckerbbc@gmail.com	Cedar Rapids	Linn	Iowa	Kenny McCracken	Corey Becker	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Allen Becker	mike4bbc@gmail.com	Brother/Partner	Cedar Rapids	Linn	Iowa	Kenny McCracken	Corey Becker	Signed
927	2022-02-17 16:22	Anonymous (not verified)	174.215.244.78	Mike Benson dba Standard Drywall	Proprietorship	1713 w7th st. Waterloo iowa 50702	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-17	Michael Arlyn Benson	mikekimbenson@gmail.com	Waterloo	Black Hawk	Iowa	Leesa Marie Wheeler	Austin Michael Thorpe	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Arlyn Benson	mikekimbenson@gmail.com	Self	Waterloo	Black Hawk	Iowa	Leesa Marie Wheeler	Austin Michael Thorpe	Signed
236	2020-08-18 16:15	Anonymous (not verified)	173.28.28.57	Michael Ballhagen	Proprietorship	279 Pine Street, Allison IA 50602	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-07	Michael Ballhagen	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Ballhagen	cmins_re@mchsi.com	Self	Allison	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
1217	2022-07-21 06:51	Anonymous (not verified)	209.152.88.53	Bullard Accounting Services, LLC	Limited Liability Company	4519 Scouts View Dr, Central City, IA 52214	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-21	Michael Bullard	mikeandkarenbullard@gmail.com	CENTRAL CITY	IA	United States	Karen Bullard	Nicole Nassif	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Bullard	mikeandkarenbullard@gmail.com	President of Company	CENTRAL CITY	IA	United States	Karen Bullard	Nicole Nassif	Signed
275	2020-10-08 11:56	Anonymous (not verified)	166.224.213.71	Michael corcoran	Proprietorship	311 e elm st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-07	Michael corcoran	mikecorcoran1990@gmail.com	West Union	Fayette	IA	Heather corcoran	Chris Fels	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael corcoran	mikecorcoran1990@gmail.com	Self	West Union	Fayette	IA	Heather corcoran	Chris fels	Signed
2108	2024-03-20 12:51	Anonymous (not verified)	94.188.207.230	Mc Storm Restortion Services	Limited Liability Company	1913 NE LITTLE BEAVER 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.	2024-03-20	Michael Cross	crossmichael1@hotmail.com	Grimes	IA	United States	Courtney Lesher	Chandler Steffy	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Cross	crossmichael1@hotmail.com	owner	Grimes	IA	United States	Courtney Lesher	Chandler Steffy	Signed
895	2022-02-04 11:57	Anonymous (not verified)	216.189.133.155	A1A Sandblasting (Iowa)	Proprietorship	334 main street S.W.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-04	michael d marjama	mike.orie@yahoo.com	menahga	MN	United States	Josh Louviere	Kevin Tomperi	Signed	(1) The employer does not elect the employers’ liability coverage.	michael d marjama	mike.orie@yahoo.com	Owner	menahga	MN	United States	Josh Louviere	Kevin Tomperi	Signed
317	2020-11-15 19:20	Anonymous (not verified)	172.58.83.192	All Cut Lawn Care	Proprietorship	3506 Glover Ave. Des Moines Iowa 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-11-15	Michael D Money	michaelmoney883@gmail.com	Des Moines	Polk	Iowa	Deanna L Phagan	Diana J Jennings	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael D Money	michaelmoney883@gmail.com	Myself	Des Moines	Polk	Iowa	Deanna L Phagan	Diana J Jennings	Signed
1707	2023-06-25 10:39	Anonymous (not verified)	94.188.207.224	Michael D Ray	Proprietorship	4944 Holcomb Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-22	Michael D Ray Jr	mdray01@msn.com	Des Moines	Polk	Iowa	Bonnie R Finken	Isaiah O Washington	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael D Ray	mdray01@msn.com	Owner Proprietor	Des Moines	Polk	Iowa	Bonnie R Finken	Isaiah O Washington	Signed
1698	2023-06-20 16:43	Anonymous (not verified)	94.188.205.167	Mike farrell	Proprietorship	306 ne trilein dr ankeny,ia 50021	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-20	Michael David farrell	farrellsfmr@yahoo.com	Ankeny	Polk	Ia	ERICK SCHULST	Kelly Coluzzi	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael David farrell	farrellsfmr@yahoo.com	Owner	Ankeny	Polk	Iowa	Erick Schuldr	Kelly .Coluzzi3	Signed
809	2021-12-21 14:42	Anonymous (not verified)	75.162.173.166	Mike Money	Proprietorship	3506 Glover Ave. Des Moines, Iowa 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-21	Michael David Money	poojennings78@gmail.com	Des Moines	Polk	Iowa	Diana Jennings	Steve Jennings	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael David Money	poojennings78@gmail.com	self	Des Moines	Polk	Iowa	Diana Jennings	Steve Jennings	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
1052	2022-04-14 19:05	Anonymous (not verified)	140.82.187.220	McHaddy Constuction	Proprietorship	423 Railroad St.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-14	Mick Haddeman	mick@mchaddyconstruction.com	Hudson	Iowa	United States	Linsey Jo Haddeman	Jordan Renae Haddeman	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Haddeman	mick@mchaddyconstruction.com	self	Hudson	IA	United States	Linsey Jo Haddeman	Jordan Renae Haddeman	Signed
290	2020-10-23 15:13	Anonymous (not verified)	74.42.24.42	Gunter Trucking LLC	Limited Liability Company	704 River Ave N., Belmond, IA 50421	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-23	Michael James Gunter	mikegunter885@yahoo.com	Belmond	Wright	Iowa	Sondra Faye Godsell	Lori Lynn Studer	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael James Gunter	mikegunter885@yahoo.com	Owner	Belmond	Wright	Iowa	Sondra Faye Godsell	Lori Lynn Studer	Signed
96	2020-03-19 12:11	Anonymous (not verified)	173.24.181.211	JENSEN GROUP LP	Limited Liability Partnership	PO BOX 721 ARNOLDS PARK, IA 51331	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-18	MICHAEL JENSEN	Michael@BuyGreatLakes.com	ARNOLDS PARK	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	MICHAEL JENSEN	JOEL@WALKERINSURANCE.COM	PARTNER	ARNOLDS PARK	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed
1957	2023-12-14 18:34	Anonymous (not verified)	94.188.205.166	Renewal by Andersen	Limited Liability Company	5909 OMAHA AVE N STILLWATER, MN, 55082	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-14	Nicholas T Campbell	hgchomes@gmail.com	Pleasant Hill	Polk	Iowa	Randall D Campbell	Lucas S Campbell	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Kaut	michael@rbadesmoines.com	Employee	Pleasant Hill	Polk	Iowa	Randall D Campbell	Lucas S Campbell	Signed
1962	2023-12-17 18:48	Anonymous (not verified)	94.188.207.223	HGC Homes LLC	Limited Liability Company	6795 NE Rising Sun Dr 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.	2023-12-17	Nicholas T Campbell	hgchomes@gmail.com	Pleasant Hill	Polk	Iowa	Randall D Campbell	Lucas S Campbell	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Kaut	michael@rbadesmoines.com	None	Pleasant Hill	Polk	Iowa	Randall D Campbell	Lucas S Campbell	Signed
412	2021-02-23 14:23	Anonymous (not verified)	205.185.135.176	Jeffrey Meyer	Proprietorship	118 1st St SE New Albin IA 52160	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-23	Jeffrey Meyer	meyertimberservices@gmail.com	New Albin	Allamakee	Iowa	Michael Klug	Kayla Snitker	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Klug	mike@aibme.com	Insurance Agent	Caledonia	Houston	Minnesota	Jeffrey Meyer	Kayla Snitker	Signed
2007	2024-01-29 13:13	Anonymous (not verified)	94.188.205.174	Saratoga Seamless Gutters LLC	Limited Liability Company	10328 Howard Ave, Lime Springs, IA 52155	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-29	Michael Langlais	saratogaseamlessgutters@gmail.com	Lime Springs	Howard	IA	Amanda Doty	Michaela Langlais	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Langlais	saratogaseamlessgutters@gmail.com	Owner	Lime Springs	Howard	IA	Amanda Doty	Michaela Langlais	Signed
816	2021-12-30 09:56	Anonymous (not verified)	174.199.83.133	Michael Fales	Proprietorship	1987 180th Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-30	Michael Lee Fales	Chubby__69@hotmail.com	Canby	Yellow Medicine	Minnesota	Tori Fales	Jean Fales	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Lee Fales	Chubby__69@hotmail.com	Owner	Canby	Yellow Medicine	Minnesota	Tori Fales	Jean Fales	Signed
371	2021-01-22 14:25	Anonymous (not verified)	71.39.227.238	Michael McClure	Proprietorship	2553 240th St, Dallas Center, IA 50063	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-22	Michael McClure	mdjj4@centurylink.net	Dallas Center	Dallas	Iowa	RoseMary Phillips	Steve Phillips	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael McClure	mdjj4@centurylink.net	Self	Dallas Center	Dallas	Iowa	RoseMary Phillips	Steve Phillips	Signed
404	2021-02-16 13:30	Anonymous (not verified)	174.198.79.179	Topline Painting llc	Limited Liability Company	1603 e 32nd 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.	2021-02-16	Michael nunez	toplinepaintingiowa@gmail.com	Des Moines	Polk	Iowa	Jimmy nunez	Jose Nunez	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael nunez	toplinepaintingiowa@gmail.com	Owner	Des moines	Polk	Iowa	Jimmy nunez	Jose nunez	Signed
1972	2024-01-02 14:19	Anonymous (not verified)	94.188.205.174	Parker Trucking LLC	Limited Liability Company	1507 Greene Street Adel, IA 50003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-02	Michael Craig Parker	mcparker31@msn.com	Adel	Dallas	Iowa	Jessie Rynearson	Melisha Rynearson	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Parker	mcparker31@msn.com	Owner/Memeber	Adel	Dallas	IA	Jessie Rynearson	Melishia Rynearson	Signed
1641	2023-05-11 13:40	Anonymous (not verified)	94.188.207.228	Mike Weigel Construction, LLC	Limited Liability Company	2528 Dalton St, Ames IA 50010-1151	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-11	Michael Patrick Weigel	mikeweigelconstruction@gmail.com	Ames	Story	Iowa	Brenda Marie Weigel	Piper Rylee Weigel	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Patrick Weigel	mikeweigelconstruction@gmail.com	Self	Ames	Story	Iowa	Brenda Marie Weigel	Piper Rylee Weigel	Signed
365	2021-01-15 11:24	Anonymous (not verified)	63.227.74.126	Paramount Kitchen and Bath	Limited Liability Company	2155 SE 37TH ST STE C	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-15	Michael Simpson	mike@paramount-kitchens.com	GRIMES	Iowa	United States	Cory Morris	Jason Andersen	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Simpson	mike@paramount-kitchens.com	Owner	GRIMES	Iowa	United States	Cory Morris	Jason Andersen	Signed
752	2021-11-17 08:22	Anonymous (not verified)	166.181.82.81	Michael sprout	Limited Liability Company	1208 N THORNWOOD AVE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-14	Michael Sprout	1293newhome@gmail.com	Davenport	IA	IA	Mike smith	Doug palmer	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Sprout	1293newhome@gmail.com	Geico	Davenport	IA	IA	Mike smith	Doug palmer	Signed
679	2021-10-18 13:14	Anonymous (not verified)	173.18.22.217	Xscape Extreme Hard & Landscape	Proprietorship	3215 E 25th CT Bldg 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.	2021-10-18	Mike Tapper	Tapper4981@gmail.com	Des Moines	Polk	IA	Lesa Dillon	Kelly Coluzzi	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Tapp	Tapper4981@gmail.com	Owner	Des Moines	Des Moines	IA	Lesa Dillon	Kelly Coluzzi	Signed
1415	2023-01-09 10:50	Anonymous (not verified)	73.103.30.27	MWK Solutions, LLC	Limited Liability Company	1001 South Park St., Fairfield, IA 52556	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-09	Michael Wayne Koch	mwkpar@gmail.com	Fairfield	Jefferson	Iowa	Ann Koch	David Fleming	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Wayne Koch	mwkpar@gmail.com	Self	Fairfield	Jefferson	Iowa	Ann Koch	David Fleming	Signed
793	2021-12-14 14:16	Anonymous (not verified)	174.22.96.99	Dubuque County Energy District	Limited Liability Company	700 Locust Street, #195	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-10	Michaela Marie Freiburger	michaela@energydistrict.org	Dubuque	Dubuque	IA	Diane Freiburger, Mother	Michael Freiburger, Father	Signed	(1) The employer does not elect the employers’ liability coverage.	Michaela Marie Freiburger	michaela@energydistrict.org	Contracted Vendor for the Dubuque County Energy District	Dubuque	Dubuque	IA	Diane Freiburger	Michael Freiburger	Signed
1268	2022-08-18 15:01	Anonymous (not verified)	75.162.65.221	Furgy's Carpet	Limited Liability Company	6930 NE 56th St Lot 92, Altoona, IA 50009	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-18	Micheal Furgison	furgy4f@gmail.com	Altoona	Polk	Iowa	Randy Lacina	Laura Lacina	Signed	(1) The employer does not elect the employers’ liability coverage.	Micheal Furgison	furgy4f@gmail.com	Self	Altoona	Polk	Iowa	Randy Lacina	Laura Lacina	Signed
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
1500	2023-03-07 11:22	Anonymous (not verified)	94.188.205.177	KATEN LLC	Limited Liability Company	5100 S ASH GROVE AVE SIOUX FALLS, SD, 57108	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	MICHELLE KATEN	JOEL@WALKERINSURANCEIA.COM	SIOUX FALLS	MINNEHAHA	SD	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	MICHELE KATEN	JOEL@WALKERINSURANCEIA.COM	SELF	SIOUX FALLS	MINNEHAHA	SD	JOSEPH THOMAS LORINGJ	JENNIFER JANET YOUNGWIRTH	Signed
794	2021-12-14 14:18	Anonymous (not verified)	65.144.174.26	iDesign	Limited Liability Company	805 15th St, Dallas Center, IA 50063	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-14	Michelle Wiedman	idesigninside@gmail.com	Dallas Center	Dallas	IA	Carl Sprague	Neal Bunn	Signed	(1) The employer does not elect the employers’ liability coverage.	Michelle Wiedman	idesigninside@gmail.com	Self	Dallas Center	Dallas	Iowa	Carl Sprague	Neal Bunn	Signed
1495	2023-03-06 09:57	Anonymous (not verified)	94.188.207.224	Midwest Indoor Air Quality, LLC	Limited Liability Company	701 NE Brook Haven Drive, Ankeny, IA 50021	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-06	Tanner Evan Francisco	tanner.midwestindoorairquality@outlook.com	Ankeny	IA	United States	Sherry Reynolds	David Boyer	Signed	(1) The employer does not elect the employers’ liability coverage.	Midwest Indoor Air Quality, LLC	tanner.midwestindoorairquality@outlook.com	Same	Ankeny	IA	United States	Sherry Reynolds	David Boyer	Signed
839	2022-01-14 10:56	Anonymous (not verified)	173.29.218.216	Midwest Solar Services, LLC	Limited Liability Company	595 Huff Street, Dubuque, IA 52003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-01-10	Tyler Billmeyer	tbillmeyer@midwestsolarservices.com	Dubuque	Dubuque	Iowa	Kim Esser	Michelle Huss	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Midwest Solar Services, LLC	kim.esser@kunkel-inc.com	Insurance Agent	Dubuque	Dubuque	Iowa	Kim Esser	Michelle Huss	Signed
840	2022-01-14 10:58	Anonymous (not verified)	173.29.218.216	Midwest Solar Services, LLC	Limited Liability Company	595 Huff Street, Dubuque, IA 52003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-01-10	Matthew Shear	mshear@midwestsolarservices.com	Dubuque	Dubuque	Iowa	Kim Esser	Michelle Huss	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Midwest Solar Services, LLC	kim.esser@kunkel-inc.com	Insurance Agent	Dubuque	Dubuque	Iowa	Kim Esser	Michelle Huss	Signed
841	2022-01-14 15:23	Anonymous (not verified)	173.29.218.216	Midwest Solar Services, LLC	Limited Liability Company	595 Huff Street, Dubuque, IA 52003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-01-10	Matthew Shear	mshear@midwestsolarservices.com	Hanover	Jo Daviess	IL	Kim Esser	Michelle Huss	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Midwest Solar Services, LLC	kim.esser@kunkel-inc.com	Insurance Agent	Dubuque	Dubuque	Iowa	Kim Esser	Michelle Huss	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
754	2021-11-19 08:27	Anonymous (not verified)	65.144.174.26	miguel albino	Proprietorship	8760 cody dr. unit 107 west des moines	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-19	miguel albino	albino.miguel627@gmail.com	west des moines	united states	iowa	humbeto albino	johnothan albino	Signed	(1) The employer does not elect the employers’ liability coverage.	miguel albino	albino.miguel627@gmail.com	self	west des moines	united states	iowa	humberto albino	johnothan	Signed
180	2020-06-09 13:35	Anonymous (not verified)	99.203.113.208	Z & Sons handyman company LLC	Limited Liability Company	2701 E Market St Des Moines Iowa 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-09	Miguel Angel Zuniga	mazuniga123678@gmail.com	Des Moines	Polk	Iowa	Rosario Zuniga	Christina Zuniga	Signed	(1) The employer does not elect the employers’ liability coverage.	Miguel Angel Zuniga	mazuniga123678@gmail.com	Z & Sons handyman company LLC is owned by agent	Des Moines	Polj	Iowa	Rosario Zuniga	Christina Zuniga	Signed
181	2020-06-09 20:44	Anonymous (not verified)	75.162.15.198	Z & Sons handyman company LLC	Limited Liability Company	2701 E Market St Des Moines Iowa 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-09	Miguel Angel Zuniga	mazuniga123678@gmail.com	Des Moines	Polk	Iowa	Rosario Zuniga	Christina Zuniga	Signed	(1) The employer does not elect the employers’ liability coverage.	Miguel Angel Zuniga	mazuniga123678@gmail.com	Z & Sons handyman company LLC is owned by agent	Des Moines	Polk	Iowa	Rosario Zuniga	Christina Zuniga	Signed
1602	2023-04-25 20:10	Anonymous (not verified)	94.188.207.228	Miguel D.	Limited Liability Company	1221 22nd 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.	2021-11-21	Miguel Duron	Duron6478@gmail.com	Des moines	Polk	Ia	Uziel martinez	Cesar jaz	Signed	(1) The employer does not elect the employers’ liability coverage.	Miguel Duron	Diron6478@gmail.com	Self	Des moines	Polk	Iowa	Uziel Martinez	Cesar jaz	Signed

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