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:
110	2020-04-06 14:13	Anonymous (not verified)	99.203.98.177	Stifel seasonal services	Limited Liability Company	935 4th street waukee	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-06	Dalton Stifel	daltonstifel@icloud.com	waukee	Dallas	IA	Bryant ternes	Tammy stifel	Signed	(1) The employer does not elect the employers’ liability coverage.	Dalton Stifel	daltonstifel@icloud.com	Owner	waukee	Dallas	IA	Bryant Ternes	Tammy Stifel	Signed
171	2020-06-01 16:17	Anonymous (not verified)	99.203.98.130	Jose Jurado	Limited Liability Company	3825 NE 43rd ct 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.	2020-06-01	Jose Jurado	trustedroofingllc@gmail.com	Des Moines	Polk	IOWA	Sterling Bean	Sigifredo Corral	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Jurado	trustedroofingllc@gmail.com	Marcos Jurado	Des Moines	Polk	IOWA	Sterling Bean	Sigifredo Corral	Signed
272	2020-10-02 13:10	Anonymous (not verified)	99.203.92.229	Batres Homes Renovation LLC	Limited Liability Company	3000 2nd Ave Des Moines Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-02	Gabriel Antonio Batres Huezo	gabirlebatres7@gmail.com	Des Moines	Polk	Iowa	Blanca Silvia Leiva	Luis Mariano	Signed	(1) The employer does not elect the employers’ liability coverage.	Walter Alexander Batres Huezo	wbatres12@gmail.com	Employer	Des Moines	Polk	Iowa	Blanca Silvia Leiva	Luis Mariano	Signed
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
220	2020-08-02 13:45	Anonymous (not verified)	99.203.112.113	R&G SEAMLESS GUTTERS	Proprietorship	3244 Dubuque Ave, 3244 Dubuque Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-02	Ruben Munoz Haro	munozharoruben@gmail.com	Des Moines	Polk	Estados Unidos	Gabriel Ramirez	Adriana Ramirez	Signed	(1) The employer does not elect the employers’ liability coverage.	Ruben Munoz- R&G SEAMLESS GUTTERS	Munozharoruben@gmail.com	owner	3244 Dubuque Ave Des Moines Iowa 50317	polk	iowa	Gabriel Ramirez	Adriana Ramirez	Signed
432	2021-03-11 18:17	Anonymous (not verified)	99.196.90.45	A-Z Tree Service	Proprietorship	1128 W 124th St S	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-11	Daniel Keeney	dansatoztreeservice@gmail.com	Colfax	Jasper	Iowa	David Short	Brandon Vriezlaar	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Keeney	dansatoztreeservice@gmail.com	Sole Proprietor	Colfax	Jasper	Iowa	David Short	Brandon Vriezlaar	Signed
280	2020-10-20 08:02	Anonymous (not verified)	98.23.12.154	Peters Painting	Proprietorship	11286 290th Manning IA 51455	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-20	gregory peters	rangreg@windstream.net	Manning	Carroll	IA	Amy Hansen	Todd Stadtlander	Signed	(1) The employer does not elect the employers’ liability coverage.	Gregory Peters	rangreg@windstream.net	self	Manning	Carroll	IA	Amy Hansen	Todd Stadtlander	Signed
495	2021-04-23 11:26	Anonymous (not verified)	98.22.221.1	T & S Industries Inc	Partnership	200 West Jefferson	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-23	Tim Hunter	tands@iowatelecom.net	Afton	IA	IA	Cindy R Harper	Richard Mordock	Signed	(1) The employer does not elect the employers’ liability coverage.	Travelers Insurance	lisa@allplansins.com	agent	Afton	IA	IA	Cindy R Harper	Richard Mordock	Signed
1219	2022-07-21 12:39	Anonymous (not verified)	98.22.2.115	Keeling Services	Proprietorship	3190 SE 64th St, pleasant Hill, IA 50327	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-21	Josh keeling	Joshuakeeling110@gmail.com	Pleasant Hill	Iowa	United States	Kali Keeling	Matthew Keeling	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Bond	mbond@leaffilter.com	Regional sales manager	Grimes	Polk	Iowa	Kali Keeling	Matthew Keeling	Signed
804	2021-12-16 21:51	Anonymous (not verified)	98.21.205.195	Kustom Home Improvements	Proprietorship	400 Davidson st New Virginia Iowa 50210	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-16	Curtis Allen Masterson	kustomhomeimprovements.dk@gmail.com	New Virginia	Warren	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed	(1) The employer does not elect the employers’ liability coverage.	David Jack Kimmel	kustomhomeimprovements.dk@gmail.com	Self	New Virginia	Warren	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed
802	2021-12-16 21:44	Anonymous (not verified)	98.21.205.195	Kustom Home Improvements	Proprietorship	400 Davidson St New Virginia Iowa 50210	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-16	Jeffrey Allen Webster	kustomhomeimprovements.dk@gmail.com	New Virginia	Warren	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed	(1) The employer does not elect the employers’ liability coverage.	David Jack Kimmel	kustomhomeimprovements.dk@gmail.com	Self	New Virginia	Warren	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed
803	2021-12-16 21:47	Anonymous (not verified)	98.21.205.195	Kustom Home Improvements	Proprietorship	400 Davidson St New Virginia Iowa 50210	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-16	Ethan Willett	kustomhomeimprovements.dk@gmail.com	Osceola	Clarke	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed	(1) The employer does not elect the employers’ liability coverage.	David Jack Kimmel	kustomhomeimprovements.dk@gmail.com	Self	New Virginia	Warren	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed
801	2021-12-16 21:35	Anonymous (not verified)	98.21.205.195	Kustom Home Improvements	Proprietorship	400 Davidson st new Virginia Iowa 50210	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-16	David Jack Kimmel	kustomhomeimprovements.dk@gmail.com	New Virginia	Warren	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed	(1) The employer does not elect the employers’ liability coverage.	David Jack Kimmel	kustomhomeimprovements.dk@gmail.com	Self	New Virginia	Warren	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed
174	2020-06-05 15:10	Anonymous (not verified)	98.21.202.208	Bloomfield Properties LLC	Limited Liability Company	206 Weaver Road, Bloomfield, IA 52537	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-05	Terri Roberts	terri_roberts58@yahoo.com	Ottumwa	Wapello	Iowa	Sheri Moore	Cassidy Dimmitt	Signed	(1) The employer does not elect the employers’ liability coverage.	Terri Roberts	terri_roberts58@yahoo.com	shareholder	Ottumwa	Wapello	Iowa	Sheri Moore	Cassidy Dimmitt	Signed
175	2020-06-05 15:14	Anonymous (not verified)	98.21.202.208	Bloomfield Properties LLC	Limited Liability Company	206 Weaver Road, Bloomfield, IA 52537	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-05	Dave Lawrence	terri_roberts58@yahoo.com	Ottumwa	Wapello	Iowa	Sheri Moore	Cassidy Dimmitt	Signed	(1) The employer does not elect the employers’ liability coverage.	Terri Roberts	terri_roberts58@yahoo.com	shareholder	Ottumwa	Wapello	Iowa	Sheri Moore	Cassidy Dimmitt	Signed
72	2020-02-21 09:43	Anonymous (not verified)	98.18.174.183	Forrest E. Whitford DVM LLC	Limited Liability Company	P.O. Box 120 - 507 Washington Street, Volga, IA 52077	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-21	Forrest E. Whitford, DVM LLC	gfw54@hotmail.com	Volga, IA	Clayton	Iowa	Glenna Whitford	Pam Vaske	Signed	(1) The employer does not elect the employers’ liability coverage.	Forrest E. Whitford, DVM LLC	gfw54@hotmail.com	self	Volga	Clayton	Iowa	Glenna Whitford	Pam Vaske	Signed
482	2021-04-14 21:21	Anonymous (not verified)	98.17.35.5	K3 Recycling LLC	Limited Liability Company	14801 180th Ave, Milo, IA 50166	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-14	Charles Raymond Kappelman	charliekappelman@yahoo.com	MILO	Warren	United States	Ryan Matthew Kappelman	John Allen Bahr	Signed	(1) The employer does not elect the employers’ liability coverage.	K3 Recycling LLC	charliekappelman@yahoo.com	Co-owner	Milo	Warren	Iowa	Ryan Matthew Kappelman	John Allen Bahr	Signed
282	2020-10-21 07:00	Anonymous (not verified)	98.16.114.26	Fine Cut Lawn Service, LLC	Limited Liability Partnership	110 E Street, SW. P.O. Box 835 Melcher, IA. 50163	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-19	Eric E Benz	eric@finecutwaterscapes.com	Melcher	Marion	IA	Angelia Warner	Allen Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Eric Eugene Benz	eric@finecutlawn.com	same person	Melcher	Marion	IA	Angela Warner	Allen Smith	Signed
1388	2022-12-10 22:42	Anonymous (not verified)	98.156.163.144	Springfield Staffing Solution	Limited Liability Company	14918 Tuff Rd, Manor TX 78653	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-10	Oluchukwu Nwokoye	oly@springfieldstaffing.com	Manor	Travis	United States	Beluchukwu R Ebede	Oluchukwu Nwokoye	Signed	(1) The employer does not elect the employers’ liability coverage.	Beluchukwu Ebede	admin@springfield-staffing.com	Partner	Manor	Travis	United States	Beluchukwu R Ebede	Oluchukwu Nwokoye	Signed
1387	2022-12-10 22:39	Anonymous (not verified)	98.156.163.144	Springfield Staffing Solution	Limited Liability Company	14918 Tuff Rd, Manor TX 78653	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-10	Beluchukwu Ebede	admin@springfield-staffing.com	Manor	Travis	United States	Oluchukwu Nwokoye	Beluchukwu Ebede	Signed	(1) The employer does not elect the employers’ liability coverage.	Beluchukwu Ebede	admin@springfield-staffing.com	Self	Manor	Travis	United States	Oluchukwu Nwokoye	Beluchukwu Ebede	Signed
545	2021-06-22 12:58	Anonymous (not verified)	97.88.95.170	Peter L. Viscusi	Proprietorship	328 Jones Avenue, Warrensburg, MO 64093	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-06-22	Peter L. Viscusi	pviscusi@charter.net	Warrensburg	Johnson	Missouri	Bradley S. McGuffey	Randel C. Kyle	Signed	(1) The employer does not elect the employers’ liability coverage.	Peter L. Viscusi	pviscusi@charter.net	Self	Warrensburg	Johnson	Missouri	Bradley S. McGuffey	Randel C. Kyle	Signed
206	2020-07-16 08:18	Anonymous (not verified)	97.64.194.122	Tommy Messino	Proprietorship	205 S Taylor St., Cherry, IL 61317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-10	Tommy Messino	kschumacher@tricorinsurance.com	Cherry	Bureau	IL	Russell Masartis	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Tommy Messino	kschumacher@tricorinsurance.com	Same	Cherry	Bureau	IL	Russell Masartis	Shuree Behr	Signed
244	2020-08-25 13:32	Anonymous (not verified)	97.64.194.122	Soren Henriksen	Proprietorship	2165 Roosevelt St., Dubuque, IA 52001	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-20	Soren Henriksen	kschumacher@tricorinsurance.com	Dubuque	Dubuque	IA	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	Soren Henriksen	kschumacher@tricorinsurance.com	Same	Dubuque	Dubuque	IA	Russell Masartis	Nancy Wortley	Signed
421	2021-03-04 07:33	Anonymous (not verified)	97.64.185.162	Malek's Lawn & Tree Service	Proprietorship	2535 Taft 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.	2021-03-04	Shane D. Malek	Info@Malektreeservice.com	Garner	Hancock	Iowa	Tod R. Christensen	Saundra N. Formanek	Signed	(1) The employer does not elect the employers’ liability coverage.	Shane D. Malek	Info@malektreeservice.com	Owner	Garner	Hancock	Iowa	Tod R. Christensen	Saundra N. Formanek	Signed
48	2020-01-29 13:52	Anonymous (not verified)	97.64.170.98	DARIN J. KESSLER	Proprietorship	1236 25TH ST AMES, IA 50010	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-29	DARIN J. KESSLER	darinjkessler@gmail.com	AMES	STORY	IOWA	HEATHER DIANNE LANNING	JENNY ANN ARENDS	Signed	(1) The employer does not elect the employers’ liability coverage.	DARIN J. KESSLER	darinjkessler@gmail.com	SELF	AMES	STORY	IOWA	HEATHER DIANNE LANNING	JENNY ANN ARENDS	Signed
212	2020-07-20 16:43	Anonymous (not verified)	97.64.164.30	Bernard L. Gradoville D.D.S.	Proprietorship	2800 Ingersoll Ave.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-20	Bernard Gradoville	bgradoville@ingersollfamilydentistry.com	Des Moines	IA	United States	Tricia Wilson	Jack Gradoville	Signed	(1) The employer does not elect the employers’ liability coverage.	Bernard Gradoville	bgradoville@ingersollfamilydentistry.com	self	Des Moines	IA	United States	Tricia Wilson	Jack Gradoville	Signed
730	2021-11-08 14:58	Anonymous (not verified)	97.64.139.42	JZ INC	Limited Liability Company	2509 Ne 10th CT Grimes Iowa 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-08	James Zastrow	Zastrow74@gmail.com	Grimes	Iowa	United States	Kevan Wiggins	Jeremy Holmes	Signed	(1) The employer does not elect the employers’ liability coverage.	James Zastrow	zastrow74@gmail.com	Self	grimes	polk	iowa	Kevan Wiggins	Jeremy Holmes	Signed
784	2021-12-09 09:03	Anonymous (not verified)	97.64.139.42	JZ INC	Limited Liability Company	2509 Ne 10th CT Grimes Iowa 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-08	James Scott Zastrow	Zastrow74@gmail.com	Grimes	IA	United States	NIcole Zastrow	Kevan Wiggins	Signed	(1) The employer does not elect the employers’ liability coverage.	James scott Zastrow	loffredon@aol.com	Self	Grimes	IA	United States	nicole zastrow	Kevan wiggins	Signed
74	2020-02-24 15:00	Anonymous (not verified)	97.64.133.18	Sky Roofing LLC	Partnership	1332 Idaho St., Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-01	Ramiro Jurado Gomez	Liberty21424@gmail.com	Des Moines	Polk	IA	Valerie Cramer	David Murray	Signed	(1) The employer does not elect the employers’ liability coverage.	Valerie Cramer	cramerlaw@halousa.com	Attorney	Des Moines	Polk	Iowa	David Murray	Sara McGinnis	Signed
75	2020-02-24 15:03	Anonymous (not verified)	97.64.133.18	Sky Roofing LLC	Partnership	1332 Idaho St., Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-01	Ramiro Jurado Bucio	Liberty21424@gmail.com	des moines	Polk	Iowa	Valerie Cramer	David Murray	Signed	(1) The employer does not elect the employers’ liability coverage.	Valerie Cramer	cramerlaw@halousa.com	Attorney	Des Moines	Polk	Iowa	David Murray	Sara McGinnis	Signed
76	2020-02-24 15:05	Anonymous (not verified)	97.64.133.18	Sky Roofing	Partnership	1332 Idaho St., Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-01	Angel Jurado	Liberty21424@gmail.com	des moines	Polk	Iowa	Valerie Cramer	David Murray	Signed	(1) The employer does not elect the employers’ liability coverage.	Cramer Law PLC	cramerlaw@halousa.com	Attorney	Polk	Polk	Iowa	Sara Mc Ginnis	David Murray	Signed
77	2020-02-24 15:07	Anonymous (not verified)	97.64.133.18	Sky Roofing LLC	Partnership	1332 Idaho St., Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-01	Victor Jurado	Liberty21424@gmail.com	des moines	Polk	Iowa	David Murray	Valerie Cramer	Signed	(1) The employer does not elect the employers’ liability coverage.	Cramer Law PLC	Liberty21424@gmail.com	Attorney	DES MOINES	POlk	Iowa	David Murray	Sara McGinnis	Signed
1341	2022-10-23 14:31	Anonymous (not verified)	97.127.255.147	Traver Home Improvement	Limited Liability Company	14150 110 th Ave. Davenport, IA 52804	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-24	Barry S Traver	traverhomeimprovement@gmail.com	Davenport	IA	United States	Denise Baughman	Joni Bryant	Signed	(1) The employer does not elect the employers’ liability coverage.	Barry S Traver	traverhomeimprovement@gmail.com	self	Davenport	IA	United States	Denise Baughman	Joni Bryant	Signed
1091	2022-05-06 09:54	Anonymous (not verified)	97.127.228.168	American Concrete	Proprietorship	2629 Sheffield dr. Davenport iowa 52806	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-06	Craig wells	craiglwells@hotmail.com	Davenport	Scott	Iowa	Kristin frymoyer	Cameron anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	DK home products	anne@dkhomeproducts.com	Sub contractor	Davenport	Scott	Iowa	Kristin frymoyer	Cameron anderson	Signed
254	2020-09-10 20:13	Anonymous (not verified)	97.127.219.61	Scott Woodward	Proprietorship	2619 west 69th St. davenport Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-10	Scott Woodward	woodwardscott2001@gmail.com	Davenport	Scott	Iowa	Scott Woodward	Scott Woodward	Signed	(1) The employer does not elect the employers’ liability coverage.	Scott Woodward	woodwardscott2001@gmail.com	Self employed	Davenport	Scott	Iowa	Scott Woodward	Scott Woodward	Signed
611	2021-08-19 15:23	Anonymous (not verified)	97.125.53.119	Rogelio Lopez Casillas	Proprietorship	1175 Office Park Road Apt 109 WDM, Iowa 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-21	Rogelio Lopez Casillas	deb@piciowa.com	West Des Moines	Polk	Iowa	Debra Stratton	Kelly K Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Rogelio Lopez Casillas	deb@piciowa.com	subcontractor	West Des Moines	Polk	Iowa	Debra Stratton	Kelly K Denger	Signed
1012	2022-03-28 14:42	Anonymous (not verified)	97.125.50.9	Charles Grimes	Proprietorship	1041 NW Victoria Ln, Waukee, IA 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-28	Charles Grimes	maurcedes98@gmail.com	Waukee	Dallas	Iowa	Dave Tomlin	Lavon Grimes	Signed	(1) The employer does not elect the employers’ liability coverage.	Charles Grimes	maurcedes98@gmail.com	self	Waukee	Dallas	IA	Dave Tomlin	Lavon Grimes	Signed
1284	2022-08-26 08:07	Anonymous (not verified)	97.125.43.203	Sindi Merida-Alvarez dba MA Construciton LLC	Limited Liability Company	2048 Lyon St Des Moines, Iowa 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-22	Sindi Merida-ALvarez	deb@piciowa.com	Des Moines	Polk	Iowa	Debra Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Sindi Merida- ALvarez	deb@piciowa.com	selk	Des Moines	Polk	Iowa	Deb Stratton	Kelly Denger	Signed
1286	2022-08-26 09:09	Anonymous (not verified)	97.125.43.203	Daniel Lugo	Proprietorship	1217 Harold Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-24	Daniel Lugo	deb@piciowa.com	Des Mpines	Polk	IA	Debra Stratton	Martin Pinon	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel LUgo	deb@piciowa.com	self	Des Moines	Polk	Iowa	Debra Stratton	Martin Pinon	Signed
1285	2022-08-26 08:22	Anonymous (not verified)	97.125.43.203	Raul Villanueva	Proprietorship	6901 SE 14th #71	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-24	Raul Villanueva	deb@piciowa.com	Des Moines	Polk	Iowa	Debra Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Raul Villanueva	deb@picowa.com	self	Des Moines	Polk	IA	Debra Stratton	Kelly Denger	Signed
1343	2022-10-25 11:25	Anonymous (not verified)	97.125.43.203	Midwest Pro Construction LLC	Limited Liability Company	1000 SE 11th St Apt 3202	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-17	Laura Garcia	deb@piciowa.com	Grimes	polk	Iowa	Debra Stratton	Kenneth Stratton	Signed	(1) The employer does not elect the employers’ liability coverage.	Laura Garcia	deb@piciowa.com	self	Grimes	Polk	Iowa	Debra Stratton	Kenneth Stratton	Signed
1339	2022-10-18 14:14	Anonymous (not verified)	97.125.41.64	Juan Buenrostro	Proprietorship	2122 E 39th 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.	2022-10-18	Juan Buenrostro	juanjosebuenrostro@gmail.com	Des Moines	Polk	IA	Juan Buenrostro	Kelly gonzalez buenrostro	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan nisiewicz	jnisiewicz@leafhome.com	Regional recruiter	Kansas City	Clay	Missouri	Jordan nisiewicz	Jordan loyd	Signed
945	2022-03-04 10:15	Anonymous (not verified)	97.125.39.88	Solid Solutions Caulking LLC.	Limited Liability Company	1011 N. Ankeny Blvd P.O. Box 216. Ankeny Ia. 50021	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-04	Jesse Guilford	sscaulking@yahoo.com	Ankeny	Polk	Iowa	Jesse Guilford	Jade Guilford	Signed	(1) The employer does not elect the employers’ liability coverage.	Jade Guilford	sscaulking@yahoo.com	Secratary	Ankeny	Polk	Iowa	Jesse Guilford	Jade Guilford	Signed
552	2021-06-29 14:55	Anonymous (not verified)	97.125.35.240	Melo Drywall	Proprietorship	7500 Bloomfield Road Lot 78 Des Moines, Iowa 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-06-25	Marlene Bautista	bbautistamarbb@gmail.com	Des Moines	Polk	Iowa	Brian Pruitt	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Marlene Bautista	bbautistamarbb@gmail.com	self	Des Moines	Polk	Iowa	Brian Pruitt	Kelly Denger	Signed
589	2021-07-28 16:09	Anonymous (not verified)	97.125.35.240	Sotero Alonso Calderon Velasquez	Proprietorship	1312 Idaho St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-26	Sotero Alonso Calderon Velazquez	deb@piciowa.com	Des Moines	Polk	Iowa	Debra Stratton	Martin Pinon	Signed	(1) The employer does not elect the employers’ liability coverage.	Sotero Alonso Calderon Velazquez	deb@piciowa.com	subcontractor	Des MOines	Polk	Iowa	Debra Stratton	Martin Pinon	Signed
648	2021-09-21 10:03	Anonymous (not verified)	97.125.32.164	Manuel Morales	Proprietorship	1302 13th St Des Moines, Iowa 50314	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-15	Manuel Morales	deb@piciowa.com	Des Moines	Polk	Iowa	Deb Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Manuel Morales	deb@picowa.com	subcontractor	Des Moines	Polk	Iowa	Deb Stratton	Kelly Denger	Signed
640	2021-09-16 22:43	Anonymous (not verified)	97.125.255.204	Morgan Group LLC	Limited Liability Company	1124 7th St. West Des Moines, Iowa 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-16	Mackinley Charles Morgan	Morgangroupllc@gmail.com	West Des Moines	Polk	Iowa	Deborah Renee Morgan	Mark Steven Morgan	Signed	(1) The employer does not elect the employers’ liability coverage.	Mackinley Charles Morgan	Morgangroupllc@gmail.com	Owner of company	West Des Moines	Polk	Iowa	Deborah Renee Morgan	Mark Steven Morgan	Signed
1158	2022-06-17 06:34	Anonymous (not verified)	97.125.255.177	Zach Ellis	Proprietorship	3013 Se Stoneridge St Grimes ia 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-17	Zachary Ellis	zach2865@gmail.com	Grimes	IA	United States	Brittany Klien	Kennedy Ellis	Signed	(1) The employer does not elect the employers’ liability coverage.	Zachary Ellis	zach2865@gmail.com	Myself	Grimes	Polk	Iowa	Brittany Klien	Kennedy Ellis	Signed
154	2020-05-12 15:00	Anonymous (not verified)	97.125.253.184	Rundle Creations	Limited Liability Company	5816 Urbandale Avenue, Des Moines, IA 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-12	Mark Lavern Rundle II	rundlecreations@gmail.com	Des Moines	Polk	Iowa	Luis Alex Jimenez	Jennifer Lea Griffith	Signed	(1) The employer does not elect the employers’ liability coverage.	Erika Anne Rundle	rundlecreations@gmail.com	Co-Owner	Des Moines	Polk	Iowa	Luis Alex Jimenez	Jennifer Lea Griffith	Signed
1312	2022-09-17 15:29	Anonymous (not verified)	97.125.242.121	Heartland Blinds	Limited Liability Company	1255 Emmons St, Hiawatha, IA 52233	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-17	Phil Murray	proinstallia@yahoo.com	Hiawatha	Linn	IA	Jared Metcalf-Murray	Jeremy Murray	Signed	(1) The employer does not elect the employers’ liability coverage.	Christene Murray	chrissymurray57@yahoo.com	Self	Hiawatha	Linn	IA	Jared Metcalf-Murray	Jeremy Murray	Signed
673	2021-10-14 07:15	Anonymous (not verified)	97.125.239.203	Complete tile llc	Limited Liability Company	875 se gateway drive #311	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-14	Nedzad mustafic	completetile1@gmail.com	Grimes	Usa	Iowa	Enesa Mustafic	Edina avdic	Signed	(1) The employer does not elect the employers’ liability coverage.	Nedzad Mustafic	completetile1@gmail.com	Owner	Grimes	Usa	Iowa	Enesa mustafic	Edina avdic	Signed
368	2021-01-21 15:12	Anonymous (not verified)	97.125.235.64	R. A. Snow Removals, Inc	Proprietorship	525 7th St NW, 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.	2021-01-21	Robert Aaron Snow	rasnowremovals.inc@gmail.com	Altoona	Polk	Iowa	Shannon Keely Moses	Jessy James Dentler	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Aaron Snow	rasnowremovals.inc@gmail.com	President	Altoona	IA	United States	Shannon Keely Moses	Jessy James Dentler	Signed
1157	2022-06-16 07:56	Anonymous (not verified)	97.125.185.191	Apex Remodeling	Proprietorship	709 w. North 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.	2022-06-15	Nick Winters	nick.winters@apex-roofing.com	WINTERSET	Iowa	Iowa	Erin Winters	Rob Tennat	Signed	(1) The employer does not elect the employers’ liability coverage.	Nick Winters	nick.winters@apex-roofing.com	Owner	WINTERSET	Iowa	Iowa	Erin Winters	Rob Tennat	Signed
249	2020-08-28 13:06	Anonymous (not verified)	97.125.184.147	Supernova Construction LLC	Proprietorship	4665 171st St, Urbandale, IA 50323	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-28	Heraclio A Ayala	heraclio.ayala@yahoo.com	Urbandale	Dallas	IA	Ricardo Alverio	Valentin Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Heraclio Ayala	heraclio.ayala@yahoo.com	Sole Member	Urbandale	Dallas	IA	Ricardo Alverio	Valentin Garcia	Signed
246	2020-08-25 15:36	Anonymous (not verified)	97.125.173.2	MPT plumbing	Limited Liability Company	4616 147th st urbandale, ia 50323	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-25	justin lee tigges	tplumbing3@aol.com	urbandale	dallas	iowa	insurance is a scam	I would get a different issurance company	Signed	(1) The employer does not elect the employers’ liability coverage.	grinnell mutual	lori@grinnellmutual.com	insurance agent	i dont know	I don't know	iowa	what a pain in the ass	This makes no sense	Signed
1390	2022-12-12 10:27	Anonymous (not verified)	97.125.170.79	Norwalk Cleaning Servicesw	Limited Liability Company	520 W High Rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-12	Jacob Hibbert	Maryhib@icloud.com	Norwalk	IA	United States	Kyle Grandstaff	Nicole Nichols	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob Hibbert	maryhib@icloud.com	Self	Norwalk	Warren	United States	Kyle Grandstaff	Nicole Nichols	Signed
547	2021-06-24 08:05	Anonymous (not verified)	97.125.169.60	Tenant Improvement Services, LLC	Limited Liability Company	3011 Justin Drive, Urbandale, IA 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-06-24	Josh Chiles	josh@tenantimprovementsiowa.com	Des Moines	Polk	Iowa	John Martin	Johnny Holman	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Chiles	josh@tenantimprovementsiowa.com	Member	Des Moines	Polk	Iowa	John Martin	Johnny Holman	Signed
544	2021-06-21 16:10	Anonymous (not verified)	97.125.169.60	Tenant Improvement Services, LLC	Limited Liability Company	3011 Justin Drive, Urbandale, IA 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-06-21	Jake Etter	jake@tenantimprovemetnsiowa.com	Polk City	Polk	Iowa	Ashley Overton	Aylah Etter	Signed	(1) The employer does not elect the employers’ liability coverage.	Jake Etter	jake@tenantimprovementsiowa.com	Member	Polk City	Polk	Iowa	Ashley Overton	Aylah Etter	Signed
1381	2022-11-30 20:41	Anonymous (not verified)	97.125.145.12	Central Iowa Outdoor Services	Proprietorship	1213 Parkhill Dr.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-30	Keegan Eggers	CentralIowaServices1@gmail.com	Norwalk	Iowa	United States	Stephanie Eggers	Kelsie Eggers	Signed	(1) The employer does not elect the employers’ liability coverage.	Keegan Eggers	CentralIowaServices1@gmail.com	Owner	Norwalk	Iowa	United States	Stephanie Eggers	Kelsie Eggers	Signed
1018	2022-03-29 15:00	Anonymous (not verified)	97.125.143.50	Modified Originals of Winterset	Limited Liability Company	128 S 3rd Ave, 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.	2022-03-29	Daniel Maiers	Modifiedoriginals.winterset@gmail.com	Winterset	Iowa	Iowa	Mark Haddinger	Josh Williams	Signed	(1) The employer does not elect the employers’ liability coverage.	Dan Maiers	Modifiedoriginals.winterset@gmail.com	Self	Winterset	Iowa	Iowa	Mark Haddinger	Josh Williamson	Signed
630	2021-09-01 19:29	Anonymous (not verified)	97.125.133.79	Aaron J. Rosenbaum	Proprietorship	2005 Pine St, Granger, IA 50109	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-01	Aaron J. Rosenbaum	aabaum7@gmail.com	Granger	Dallas	Iowa	Bruce Klinkenberg	Trudy Rosenbaum	Signed	(1) The employer does not elect the employers’ liability coverage.	Aaron Rosenbaum	aabaum7@gmail.com	self	Granger	Dallas	Iowa	Bruce Klinkenberg	Trudy Rosenbaum	Signed
388	2021-02-10 11:48	Anonymous (not verified)	97.125.123.32	Pro Bull Painting LLC	Limited Liability Company	1204 sampson st Des Moines IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-10	Eduardo Garcia Becerril	probullpainting1@gmail.com	Des Moines	Polk	Iowa	Juan Carlos Garcia	Rigoberto Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Eduardo Garcia	Probullpainting1@gmail.com	Owner	Des moines	Polk	Iowa	Juan Carlos Garcia	Rigoberto Garcia	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
1322	2022-09-27 11:31	Anonymous (not verified)	96.31.4.134	Owens Inspection Services	Limited Liability Company	598 2nd Street SE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-01	Alexander Patrick Owe s	ap_owens_14@yahoo.com	Hospers	Sioux	Iowa	Michael Vander Wilt	Shane Meendering	Signed	(1) The employer does not elect the employers’ liability coverage.	Donald Patrick Owens	dpowens@premieronline.net	Owner	Sioux Center	Sioux	Iowa	Michael Vander Wilt	Shane Meendering	Signed
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
1382	2022-12-07 14:40	Anonymous (not verified)	96.31.1.206	IGL RENTAL LLC	Limited Liability Company	PO BOX 317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-25	AARON JONES	STAYBOJI@GMAIL.COM	ARNOLDS PARK	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	AARON JONES	STAYBOJI@GMAIL.COM	SELF	ARNOLDS PARK	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed
1314	2022-09-19 16:43	Anonymous (not verified)	96.31.1.206	CHARVEL TREJO	Proprietorship	1113 L AVE, MILFORD, 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.	2022-09-19	CHARVEL TREJO	LEVRACH@YAHOO.COM	MILFORD	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	CHARVEL TREJO	LEVRACH@YAHOO.COM	SELF	MILFORD	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed
1306	2022-09-13 15:50	Anonymous (not verified)	96.31.1.206	LUCIO PAINTING	Proprietorship	818 W 4TH ST SPENCER, IA 51301	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-06	LUCIO PENA	joel@walkerinsuranceia.com	SPENCER	CLAY	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	LUCIO PENA	joel@walkerinsuranceia.com	SELF	SPENCER	CLAY	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1383	2022-12-07 14:42	Anonymous (not verified)	96.31.1.206	IGL RENTAL LLC	Limited Liability Company	PO BOX 317 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.	2022-10-25	CHAD JONES	STAYBOJI@GMAIL.COM	ARNOLDS PARK	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	CHAD JONES	STAYBOJI@GMAIL.COM	SELF	ARNOLDS PARK	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed
1309	2022-09-15 09:58	Anonymous (not verified)	96.31.1.206	PATTONS POWDER COATING	Limited Liability Company	421 W MAPLE DRIVE HARTLEY IA 51346	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-15	DAVID PATTON	PATTONSPOWDERCOATING@GMAIL.COM	HARTLEY	OBRIEN	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	PATTONS POWDER COATING - DAVID PATTON	PATTONSPOWDERCOATING@GMAIL.COM	SELF	HARTLEY	OBRIEN	IOWA	TAMI KLEIN	JENNIFER YOUNG WIRTH	Signed
124	2020-04-16 12:07	Anonymous (not verified)	96.3.180.122	Gold Rush, LLC	Limited Liability Company	1395 130TH ST	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-16	Jay Christopher Morrow	jcmorrow2@hotmail.com	WAYLAND	Henry	IAUS	chad mitchell	Jonathan Mitchell	Signed	(1) The employer does not elect the employers’ liability coverage.	Gold Rush, LLC	jcmorrow2@gmail.com	Self	WAYLAND	Henry	IAUS	chad mitchell	Jonathan Mitchell	Signed
1426	2023-01-19 17:14	Anonymous (not verified)	96.19.118.202	Tri State Certified LLC	Limited Liability Company	4755 Mayhew Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-19	Michael Tracy	mikertracy755@gmail.com	Sioux City	IA	United States	Michael Tracy	Michael Tracy	Signed	(1) The employer does not elect the employers’ liability coverage.	Tri State Certified LLC	mikertracy755@gmail.com	Owner	Sioux City	Iowa	Iowa	Michael Tracy	Michael Tracy	Signed
1421	2023-01-13 09:43	Anonymous (not verified)	96.18.190.183	Home Base Inspection & Code Services, LLC	Limited Liability Company	3805 Ridge Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-13	Amanda Harper	amanda@hbicsvs.com	Sioux City	IA	United States	Terri Harper	Joy Brouilette	Signed	(1) The employer does not elect the employers’ liability coverage.	Amanda Harper	amanda@hbicsvs.com	self	Sioux City	IA	United States	Terri Harper	Joy Brouillette	Signed
1951	2023-12-12 13:10	Anonymous (not verified)	94.188.207.230	Patrick McGuinnis	Limited Liability Company	5697 Squire Circle, Thomson, IL 61285	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-09	Patrick A McGinnis	McGinnistrucking2023@yahoo.com	Thomson	Carroll	IL	Ashleigh McGuinnis	Kimberly Williams	Signed	(1) The employer does not elect the employers’ liability coverage.	Parick A McGunnis	mcginnistrucking2023@yahoo.com	Self	Thomson	Carroll	IL	Ashleigh McGinnis	Kimberly Williams	Signed
2034	2024-02-07 11:58	Anonymous (not verified)	94.188.207.230	Bryce Abbott	Proprietorship	114 West Linn Street, Lone Tree, IA 52755	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-31	Bryce David Abbott	bryceabbott86@gmail.com	Lone Tree	Johnson	United States	Dixie Abbott	Andy Abbott	Signed	(1) The employer does not elect the employers’ liability coverage.	Bryce Abbott	bryceabbott86@gmail.com	Self	Lonetree	Johnson	IA	Dixie Abbott	Andy Abbott	Signed
1693	2023-06-16 11:37	Anonymous (not verified)	94.188.207.230	Anthony Scroggins	Proprietorship	301 SE 11th Street , Unit 807	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-16	Anthony Scroggins	scroggins710@gmail.com	Grimes	Polk	IA	Cody Wavada	Nate Duden	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony Scroggins	scroggins710@gmail.com	Self	Grimes	Polk	IA	Cody Wavada	Nate Duden	Signed
1812	2023-08-22 08:00	Anonymous (not verified)	94.188.207.230	mike bethards	Proprietorship	3484 vermont st new virginia ia 50210	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-22	mike w bethards	mwbethards@yahoo.com	new virginia	ia	United States	christine bethards	alice lohan	Signed	(1) The employer does not elect the employers’ liability coverage.	mike bethards	mwbethards@yahoo.com	same	new virginia	ia	United States	christine bethards	alice lohan	Signed
1728	2023-07-08 10:48	Anonymous (not verified)	94.188.207.230	Lima Charlie LLC	Limited Liability Company	56066 257th Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-10	Larry Homan	larry@Lima-Charlie.biz	Glenwood	Iowa	United States	Erin Jenkins	Jeremy Jenkins	Signed	(1) The employer does not elect the employers’ liability coverage.	Larry Lee Homan	Larry@Lima-Charlie.biz	Owner	Glenwood	Iowa	United States	Erin Homan	Jeremy Jenkins	Signed
1869	2023-10-17 00:59	Anonymous (not verified)	94.188.207.230	Lisa's Janitorial	Limited Liability Company	406 S. 10th Street Sac City, Iowa 50583	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-16	Bruce Homer	bhjhomer69@gmail.com	Sac City	Sac	Iowa	Autumn Simonsen	Misty Brewster	Signed	(1) The employer does not elect the employers’ liability coverage.	Bruce Homer	bhjhomer69@gmail.com	Self	Sac City	Sac	Iowa	Autumn Simonsen	Misty Brewster	Signed
2020	2024-02-02 07:14	Anonymous (not verified)	94.188.207.230	SM4 Consulting LLC	Limited Liability Company	503 E 6TH ST	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-02	Chad Smith	sm4consultingllc@gmail.com	PRAIRIE CITY	Jasper	Iowa	Nicole Smith	Maybelle Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Chad Smith	sm4consultingllc@gmail.com	self	PRAIRIE CITY	Jasper	Iowa	Nicole Smith	Maybelle Smith	Signed
2084	2024-03-08 15:18	Anonymous (not verified)	94.188.207.230	Heidi Vincent	Proprietorship	2213 SW White Birch Dr, Ankeny, IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-18	Heidi Vincent	jared.vincent@insurancestationinc.com	Ankeny	Polk	Iowa	Jared Vincent	Colton Horak	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Schreck	mark.schreck@insurancestationinc.com	Agent	Altoona	IA	IA	Jared Vincent	Colton Horack	Signed
1637	2023-05-10 15:39	Anonymous (not verified)	94.188.207.230	Carly Roskop	Proprietorship	7706 Hampshire Ct NE Cedar Rapids, IA 52402	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-10	Carly Roskop	carlyroskop@gmail.com	Cedar Rapids	IA	United States	Dustin Roskop	Tracy Petrak	Signed	(1) The employer does not elect the employers’ liability coverage.	Carly Roskop	carlyroskop@gmail.com	Self	Cedar Rapids	IA	United States	Dustin Roskop	Tracy Petrak	Signed
2010	2024-01-30 11:46	Anonymous (not verified)	94.188.207.230	Kevin & Jlynn Jones	Proprietorship	1500 15th St. Milford Ia 51351	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-30	Jlynn Jones	KEVINMJONES81@GMAIL.COM	Milford	Dickinson	Iowa	Tami Klein	Joseph Loring	Signed	(1) The employer does not elect the employers’ liability coverage.	Kevin & Jlynn Jones	KEVINMJONES81@GMAIL.COM	Self	Milford	Dickinson	Iowa	Tami Klein	Joseph Loring	Signed
1539	2023-03-28 16:50	Anonymous (not verified)	94.188.207.230	Sulzner Construction LLC	Limited Liability Company	210 N CHERRY ST, PO BOX 264	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-28	Aksel C Sulzner	akselsmoke@gmail.com	Mechanicsville	IA	United States	self	self	Signed	(1) The employer does not elect the employers’ liability coverage.	Aksel C Sulzner	akselsmoke@gmail.com	Self	Mechanicsville	IA	United States	self	self	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
1677	2023-06-02 11:37	Anonymous (not verified)	94.188.207.230	Karl Klotzbach	Proprietorship	403 Jefferson, Decorah IA 52101	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-02	Karl Klotzbach	kdklotzbach@gmail.com	Decorah	Winneshiek	Iowa	Robin Schultz	Jane Regan	Signed	(1) The employer does not elect the employers’ liability coverage.	Karl Klotzbach	kdklotzbach@gmail.com	Employer	Decorah	Winneshiek	Iowa	Robin Schutlz	Jane M Regan	Signed
2196	2024-05-01 09:18	Anonymous (not verified)	94.188.207.230	Penaloza Stone LLC	Limited Liability Company	1530 8th 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.	2024-05-01	Javier Marcial Penaloza	javiermarcial.jmp@gmail.com	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Javier Marcial Penaloza	javiermarcial.jmp@gmail.com	Self	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed
1789	2023-08-08 13:18	Anonymous (not verified)	94.188.207.230	Corridor Construction Co., LLC	Limited Liability Company	P.O. Box 8540 Cedar Rapids, IA 52408	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-08	Steven H. Miller	jimfortmann60@gmail.com	Cedar Rapids	Linn	IA	James J. Fortmann	Ruth Ann Beers	Signed	(1) The employer does not elect the employers’ liability coverage.	Steven H. Miller	jimfortmann60@gmail.com	Member	Cedar Rapids	Linn	IA	James J. Fortmann	Ruth Ann Beers	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
1507	2023-03-09 08:16	Anonymous (not verified)	94.188.207.230	Greufe Construction	Proprietorship	2820 230th Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-01	Wayne Greufe	wgreufe@wmtel.net	Blairsburg	US	United States	Janet Greufe	Janet Greufe	Signed	(1) The employer does not elect the employers’ liability coverage.	Wayne Greufe	wgreufe@wmtel.net	Friend	Blairsburg	US	United States	Janet Greufe	Janet Greufe	Signed
1616	2023-04-27 17:46	Anonymous (not verified)	94.188.207.230	Davis AG Service Texas LLC	Limited Liability Company	P.O. Box 1475 Fabens, Texas 79838	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-27	John Anthony Davis	turbinespacemonkey@yahoo.com	Mountain View	Stone	Arkansas	Vicki Lynne Ivey	Maggielyn Marie Paul	Signed	(1) The employer does not elect the employers’ liability coverage.	John Anthony Davis	turbinespacemonkey@yahoo.com	Owner	Mountain View	Stone	Arkansas	Vicki Lynne Ivey	Maggielyn Marie Paul	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
1760	2023-07-26 08:16	Anonymous (not verified)	94.188.207.230	MCH Pig LLC	Limited Liability Company	5434 180th Ave Albert City, IA 50510	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-26	Mitchell Hogrefe	mhogrefe@nfpinc.com	Newell	Buena Vista	Iowa	Kyle Klein	Brenda Klein	Signed	(1) The employer does not elect the employers’ liability coverage.	Mitchell Hogrefe	mhogrefe@nfpinc.com	Owner	Newell	Buena Vista	Iowa	Kyle Klein	Brenda Klein	Signed
1837	2023-09-11 19:10	Anonymous (not verified)	94.188.207.230	TBA Handyman service	Limited Liability Company	619 e 10th st. north newton Iowa 50208	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-11	Joey Conkling	tba050402@gmail.com	newton	jasper	Iowa	Ashton tyler conkling	Bianca Storm Conkling	Signed	(1) The employer does not elect the employers’ liability coverage.	TBA Handyman Service	tbaconstruction02@gmail.com	self	newton	jasper	iowa	Ashton tyler Conkling	Bianca Storm Conkling	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
1908	2023-11-15 10:59	Anonymous (not verified)	94.188.207.230	Snelling Construction, LLC	Limited Liability Company	309 Railroad Ave. Tripoli, IA 50676	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-15	Spencer W. Snelling	ssnell71@yahoo.com	Tripoili	Bremer	Iowa	Michael Meyer	Shawn Pipho	Signed	(1) The employer does not elect the employers’ liability coverage.	Spencer W. Snelling	ssnell71@yahoo.com	same	Tripoli	Bremer	Iowa	Michael Meyer	Shawn Pipho	Signed
1923	2023-11-27 11:21	Anonymous (not verified)	94.188.207.230	Chilled LLC	Limited Liability Company	236 Meadow Breeze Ln Center Point IA 52213	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-27	Lindsy J Trotter	Lindsy@chilledfreezermeals.com	Center Point	Linn	Iowa	Abbie Snakenberg	Amanda Guttau	Signed	(1) The employer does not elect the employers’ liability coverage.	Lindsy Trotter	Lindsy@chilledfreezermeals.com	Owner	Center Point	Linn	Iowa	Abbie Snakenberg	Amanda Guttau	Signed
1780	2023-08-03 16:50	Anonymous (not verified)	94.188.207.230	S-N-T BRINKMAN TRANSFER LLC	Proprietorship	401 East Dewey Street Cassville, WI 53806	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-01	Todd A Brinkman	sntbrink@hotmail.com	Cassville	Wisconsin	Wisconsin	Todd A Brinkman	Todd A Brinkman	Signed	(1) The employer does not elect the employers’ liability coverage.	Todd A Brinkman	sntbrink@hotmail.com	Self employed	Cassville	Wisconsin	Wisconsin	Todd Brinkman	Todd Brinkman	Signed
2152	2024-04-15 17:23	Anonymous (not verified)	94.188.207.230	ServiceMaster by Harris	Proprietorship	432 Locust Street Waterloo, IA 50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-15	Joel Harris	joel.harris@forbin.net	Waterloo	IA	IA	None	None	Signed	(1) The employer does not elect the employers’ liability coverage.	Joel Harris	joel.harris@forbin.net	Owner	Waterloo	IA	IA	None	None	Signed
1617	2023-04-28 08:26	Anonymous (not verified)	94.188.207.230	JD Transport	Limited Liability Company	24940 247th ave Princeton Iowa 52768	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-28	Jacob Dies	jacobdiestransport@gmail.com	Princeton	Scott	Iowa	Eric Dies	Karri Dies	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob Dies	Jacobdiestransport@gmail.com	Self	Princeton	Scott	Iowa	Eric Dies	Karri Dies	Signed
1943	2023-12-06 16:34	Anonymous (not verified)	94.188.207.230	Your Neighbors Pressure Washing LLC	Limited Liability Company	2059 Lyon St Des Moines Iowa 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-06	Alejandro Bacano Rodriguez	alejandrobacanorodriguez@gmail.com	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Alejandro Bacano Rodriguez	alejandrobacanorodriguez@gmail.com	Myself	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed
1741	2023-07-12 09:38	Anonymous (not verified)	94.188.207.230	Jose Tavares	Proprietorship	1175 Office Park Road Apt 109 WDM IA 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-28	Jose Tavares	deb@piciowa.com	WDM	Polk	IA	Martin Pin on	Deb Stratton	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Tavares	deb@piciowa.com	self	WDM	Polk	IA	Martin Pinon	Deb Stratton	Signed
1757	2023-07-20 14:45	Anonymous (not verified)	94.188.207.230	Lee Steffen	Proprietorship	608 3rd Street NE, Farley, IA 52046	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-20	Lee Steffen	lee.steffen22@icloud.com	Farley	Dubuque	Iowa	Derrick Parsons	Joyce Heims	Signed	(1) The employer does not elect the employers’ liability coverage.	Lee Steffen	lee.steffen22@icloud.com	Self	Farley	Dubuque	Iowa	Derrick Parsons	Joyce Heims	Signed
1762	2023-07-26 12:42	Anonymous (not verified)	94.188.207.230	Down Home Decor, Inc	Proprietorship	1021 2nd Ave SE Ste 200 - Dyersville, IA 52040	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-26	Vicki Knipper	jheims@english-insurance.com	Dyersville	IA	IA	Joyce Heims	Derrick Parsons	Signed	(1) The employer does not elect the employers’ liability coverage.	Joyce Heims	jheims@english-insurance.com	self agent	Dyersville	IA	IA	Joyce Heims	Derrick Parsons	Signed
2066	2024-02-29 15:27	Anonymous (not verified)	94.188.207.230	Julian Abey	Proprietorship	4405 NW Abilene Road, Ankeny IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-29	Julian Abey	Jabeyhpro@gmail.com	Ankeny	Polk	IA	Eric Ndifon	Peter Gara	Signed	(1) The employer does not elect the employers’ liability coverage.	Julian Abey	Jabeyhpro@gmail.com	Self	Ankeny	IA	IA	Eric Ndifon	Peter Gara	Signed
1755	2023-07-19 22:43	Anonymous (not verified)	94.188.207.230	Ellison building and repair	Limited Liability Company	2722 645th ave moravia iowa 52571	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-19	Keeton Ellison	sammyllsn@yahoo.com	Moravia	Appanoose	Iowa	Cory Ellison	Sammy Ellison	Signed	(1) The employer does not elect the employers’ liability coverage.	Sammy Ellison	sammyllsn@yahoo.com	Mom	Moravia	Monroe	Iowa	Cory Ellison	Sammy Ellison	Signed
1668	2023-05-30 10:50	Anonymous (not verified)	94.188.207.230	Projects Under Development LLC	Limited Liability Company	2516 Hickory Grove Rd Davenport Iowa 52804	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-30	James Stock	jamese1053@gmail.com	Davenport	Scott	Iowa	Ronald Lang	Karen Stock	Signed	(1) The employer does not elect the employers’ liability coverage.	James Stock	jamese1053@gmail.com	Owener	Davenport	Scott	Iowa	Ronald Lang	Karen Walker	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
1601	2023-04-25 14:38	Anonymous (not verified)	94.188.207.230	francisco garcia	Proprietorship	388 lesley ln ne	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-25	franscisco garcia	frasicohinojosa@gmail.com	cedar rapids	linn	iowa	Ryan Klein	Karina Jacobson	Signed	(1) The employer does not elect the employers’ liability coverage.	francisco garcia	frasicohinojosa@gmail.com	N/A	cedar rapids	linn	iowa	Ryan Klein	Karina Jacobson	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
1517	2023-03-14 09:06	Anonymous (not verified)	94.188.207.230	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln ST., Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-14	James Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed	(1) The employer does not elect the employers’ liability coverage.	James Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed
2041	2024-02-12 10:37	Anonymous (not verified)	94.188.207.230	Blue Dog Stump Grinding LLC	Limited Liability Company	32199 Sumac Rd Neola, IA 51559	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-12	Zebulan Kent Wahle	bluedogstumpgrinding@gmail.com	Neola	Pottawattamie	Iowa	Kelsey Wahle	Michael Stamp	Signed	(1) The employer does not elect the employers’ liability coverage.	Zebulan Kent Wahle	bluedogstumpgrinding@gmail.com	Self	Neola	Pottawattamie	Iowa	Kelsey Wahle	Michael Stamp	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
1702	2023-06-22 22:57	Anonymous (not verified)	94.188.207.230	A&M Consulting LLC	Limited Liability Company	1208 5th Ave, North Humboldt Iowa, 50548	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	maureen Waweru	maureenrealtyaz@yahoo.com	chandler	AZ	United States	John Waweru	Jessica Bellinger	Signed	(1) The employer does not elect the employers’ liability coverage.	maureen Waweru	maureenrealtyaz@yahoo.com	Self	chandler	AZ	United States	John Waweru	Jessica Bellinger	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
2008	2024-01-29 14:45	Anonymous (not verified)	94.188.207.230	DB2P	Limited Liability Company	5904 Ashworth Road	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-29	Arjun Dahal	allcoolliquors@gmail.com	West Des Moines	Dallas	Iowa	Jayson Jones	Nikki Wilks	Signed	(1) The employer does not elect the employers’ liability coverage.	Jayson Jones	jayson@jonesinsured.com	Insurance Agent	Urbandale	Dallas	Iowa	Jayson Jones	Nikki Wilks	Signed
2143	2024-04-09 13:05	Anonymous (not verified)	94.188.207.230	CO2 Refrigeration Systems (Iowa) LLC	Limited Liability Company	315 E 5th St Ste 202, Waterloo, IA 50703	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2024-04-09	Zachary Heintz Laws	zach.laws@co2refsystems.com	Marshalltown	Marshall	Iowa	Robert E Shomo	Steven M Madsen	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Zachary Heintz Laws	zach.laws@co2refsystems.com	Self	Marshalltown	Marshall	Iowa	Robert E Shomo	Steven M Madsen	Signed
2056	2024-02-24 08:17	Anonymous (not verified)	94.188.207.230	C&C Property LLC	Limited Liability Partnership	PO Box 418	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-24	Joshua Darwin Wessel	wesselclublambs@gmail.com	Kiron	Crawford	IA	Chad D Foust	Chad A Tweeten	Signed	(1) The employer does not elect the employers’ liability coverage.	Chad Tweeten	tweeten@hotmail.com	Barn Manager 1099 employee	Eagle grove	Wright	Iowa	Chad Tweeten	Chad Foust	Signed
1814	2023-08-23 13:57	Anonymous (not verified)	94.188.207.229	Exclusive Solutions LLC dba Jovan Guerrero	Limited Liability Company	2887 Jaden Lane Norwalk, Iowa 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.	2023-07-10	Jovan guerrero dba Exclusive Solutions LLC	deb@piciowa.com	Norwalk	Polk	Ia	Debra Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Jovan Guerrero dba Exclusive SOlutions LLC	jovanguerrero29@gmail.com	self	Norwalk	Poik	Iowa	Debra Stratton	Kelly Denger	Signed
2197	2024-05-02 09:30	Anonymous (not verified)	94.188.207.229	Melvin Osorio	Proprietorship	3848 E 14th St Trlr 78, 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.	2024-05-02	Melvin Osorio	matamorosana56@gmail.com	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Melvin Osorio	matamorosana56@gmail.com	Self	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed
1548	2023-03-30 14:18	Anonymous (not verified)	94.188.207.229	Lance Jordison	Proprietorship	2295 Nelson Ave, Fort Dodge, IA 50501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-30	Lance Jordison	jordisontrucking@gmail.com	Fort Dodge	Webster	Iowa	Ashlee Neumann	Ed Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Lance Jordison	jordisontrucking@gmail.com	Owner	Fort Dodge	Webster	Iowa	Ashlee Neumann	Ed Smith	Signed
1994	2024-01-23 14:35	Anonymous (not verified)	94.188.207.229	Josh Oswald	Proprietorship	505 Eisenhower Rd., Osceola, IA 50213	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-23	Josh Oswald	jjoswald47@gmail.com	Osceola	Clarke	Iowa	Douglas Eugene Miller	Elaine Lee	Signed	(1) The employer does not elect the employers’ liability coverage.	JOSHUA OSWALD	jjoswald47@gmail.com	Sole Proprietor	Osceola	Clarke	Iowa	Douglas Eugene Miller	Elaine Lee	Signed
2159	2024-04-17 12:28	Anonymous (not verified)	94.188.207.229	Mildred Lopez Camacho	Proprietorship	214 1st Ave SW Hampton, Iowa 50441	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-17	Mildred Lopez Camacho	morrison.hpd@gmail.com	Hampton	Franklin	Iowa	Ixia Anduce	Jonathan Morales	Signed	(1) The employer does not elect the employers’ liability coverage.	Mildred Lopez Camacho	morrison.hpd@gmail.com	Self	Hampton	Franklin	IOwa	Ixia Anduce	Jonathan Morales	Signed
1987	2024-01-16 12:35	Anonymous (not verified)	94.188.207.229	Wasabi urbandale LLc	Limited Liability Company	12509 Townsend Ava, Urbandale, IA 50323	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-16	Wen Zheng	jenna18841002@hotmail.com	Urbandale	Dallas	Iowa	Jie Li	Yingna Zheng	Signed	(1) The employer does not elect the employers’ liability coverage.	Wen Zheng	jenna18841002@hotmail.com	Owner	Urbandale	Dallas	Iowas	Jie Li	Yingna zheng	Signed
1686	2023-06-12 07:45	Anonymous (not verified)	94.188.207.229	Robert Burman	Proprietorship	400 Lindale Dr 119 Marion, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-11	Robert Burman	robertburman791@gmail.com	Marion	Linn	Iowa	Charles Wood	Jordan Nisiewicz	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Charles Wood	Jordan loyd	Signed
1955	2023-12-14 09:19	Anonymous (not verified)	94.188.207.229	Protouch snow&lawn llc	Limited Liability Company	4015 sager ave waterloo	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Eric brown	brown39s@yhoo.com	Waterloo	United States	Iowa	Joe brown	Emily brown	Signed	(1) The employer does not elect the employers’ liability coverage.	Eric brown	brown39s@yahoo.com	Self	Waterloo	United States	Iowa	Emily brown	Joe brown	Signed
1783	2023-08-04 10:17	Anonymous (not verified)	94.188.207.229	Lundin trucking llc	Limited Liability Company	322 w wilson street preston iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-04	Devin dallas lundin	devinlundin@hotmail.com	Preston	Jackson	Iowa	Kathy kilburg	Greg kilburg	Signed	(1) The employer does not elect the employers’ liability coverage.	Devin lundin	devinlundin@hotmail.com	Owner	Preston	Jackson	Iowa	Kathy kilburg	Greg kilburg	Signed
1792	2023-08-08 20:19	Anonymous (not verified)	94.188.207.229	Faith Based Construction	Limited Liability Company	6820 Holcomb Ave. Apt. 8	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-08	Toby Andrew Johns	tobyjohns28@gmail.com	URBANDALE	Polk	United States	Melanie Jo Ayersman	Emma Stover	Signed	(1) The employer does not elect the employers’ liability coverage.	Toby Andrew Johns	tobyjohns28@gmail.com	self	URBANDALE	Polk	United States	Melanie Jo Ayersman	Emma Stover	Signed
1676	2023-06-02 09:41	Anonymous (not verified)	94.188.207.229	Kacena Family Tree Farm Inc	Partnership	2510 55th St., Vinton, IA 52349	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-01	Debra Kacena	kacenafarms.alyce@gmail.com	Vinton	Benton	Iowa	Ashlyn J. Christianson	Angie McFarland	Signed	(1) The employer does not elect the employers’ liability coverage.	Alyce Lynch	ashlyn@3riversins.net	25% Owners - President	Vinton	Benton	Iowa	Ashlyn J. Christianson	Angie McFarland	Signed
1986	2024-01-16 12:18	Anonymous (not verified)	94.188.207.229	Wasabi Urbandale LLC	Limited Liability Company	2965 Se Timberline dr , Waukee , Iowa 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-16	Enjinzheng	jimmyzheng1573@gmail.com	Waukee	Dallas	Iowa	Jie Li	Yingnazheng	Signed	(1) The employer does not elect the employers’ liability coverage.	Enjin zheng	jimmyzheng1573@gmail.com	Owner	Waukee	Dallas	Iowa	Jie Li	Yingna zheng	Signed
2220	2024-05-10 11:10	Anonymous (not verified)	94.188.207.229	Froyo To Go, LLC	Limited Liability Company	909 4th Ave S., Denison, Iowa 51442	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-10	Lucas Gillmor	lgillmor@dmuonline.com	Denison	Crawford	Iowa	Maria Sandoval	Nahomy Fernandez Alvarado	Signed	(1) The employer does not elect the employers’ liability coverage.	Trevis Beeck	trevis.beeck.u0ms@statefarm.com	State Farm Agent	Denison	Crawford	Iowa	Maria Sandoval	Nahomy Fernandez Alvarado	Signed
1492	2023-03-03 16:09	Anonymous (not verified)	94.188.207.229	Sean Aldrich LLC	Limited Liability Company	408 n.7th st. Indianola iowa 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.	2023-03-03	Sean Kenneth Aldrich	sean.aldrich74@gmail.com	Indianola	Warren	Iowa	Madeline Jenelle Aldrich	John Thomas Aldrich	Signed	(1) The employer does not elect the employers’ liability coverage.	Sean Kenneth Aldrich	sean.aldrich74@gmail.com	Self	Indianola	Warren	Iowa	Madeline Jenelle Aldrich	John Thomas Aldrich	Signed
2039	2024-02-08 09:25	Anonymous (not verified)	94.188.207.229	Home Re Construction, LLC	Limited Liability Company	5285 NE Mitchell Drive, Mitchellville, IA 50169	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-08	Francisco Miguel Palomares Velasco	homereconstruction@hotmail.com	Mitchellville	Polk	Iowa	Fabiola Palomares Recendiz	Nathan Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Francisco Miguel Palomares Velasco	homereconstruction@hotmail.com	Self	Mithcellville	Polk	Iowa	Fabiola Palomares Recendiz	Nathan Miller	Signed
1605	2023-04-26 09:48	Anonymous (not verified)	94.188.207.229	Double Barrell Construction	Proprietorship	1237 S 52nd St, #804, West Des Moines, IA 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-26	Braedyn Baylor	bbaylor66@gmail.com	West Des Moines	Polk	IA	Peggy Toft	Rick Thompson	Signed	(1) The employer does not elect the employers’ liability coverage.	Braedyn Baylor	bbaylor66@gmail.com	Owner	West Des Moines	Polk	IA	Peggy Toft	Rick Thompson	Signed
1935	2023-12-02 18:34	Anonymous (not verified)	94.188.207.229	Wasabi Johnston LLC	Limited Liability Company	8184 Birchwood Ct, Johnston IA 50131	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-02	Jay Wang	jaywang@wasabidsm.com	Clive	Dallas	IA	Engjin zheng	yingna Zheng	Signed	(1) The employer does not elect the employers’ liability coverage.	Jay Wang	jaywang@wasabidsm.com	self	Clive	Dallas	IA	Wenhui Cheng	Enjing Zheng	Signed
1674	2023-06-02 09:34	Anonymous (not verified)	94.188.207.229	Kacena Family Tree Farm Inc	Partnership	2510 55th St., Vinton, IA 52349	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-01	Kyle Lynch	kacenafarms.alyce@gmail.com	Vinton	Benton	Iowa	Ashlyn J. Christianson	Angie McFarland	Signed	(1) The employer does not elect the employers’ liability coverage.	Alyce Lynch	ashlyn@3riversins.net	25% Owner - President	Vinton	Benton	Iowa	Ashlyn J. Christianson	Angie McFarland	Signed
1599	2023-04-25 14:38	Anonymous (not verified)	94.188.207.229	luis contreras	Proprietorship	433 8th ave 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.	2023-04-25	luis contreras	luisayala781@gmail.com	cedar rapids	linn	iowa	Ryan Klein	Karina Jacobson	Signed	(1) The employer does not elect the employers’ liability coverage.	luis contreras	luisayala781@gmail.com	N/A	cedar rapids	linn	iowa	Ryan Klein	Karina Jacobson	Signed
1965	2023-12-22 10:23	Anonymous (not verified)	94.188.207.229	Shawn Cooney	Proprietorship	4425 Ne 34th Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-22	Shawn Nelson Cooney	shawncooney59@gmail.com	Des Moines	polk	IA	Marie Cooney	Shawntel Cooney	Signed	(1) The employer does not elect the employers’ liability coverage.	Shawn Cooney	shawncooney59@gmail.com	Myself	Des Moines	polk	IA	Marie Cooney	Shawntel Cooney	Signed
1655	2023-05-19 14:19	Anonymous (not verified)	94.188.207.229	Cutting Edge Concrete LLC	Limited Liability Company	325 Linn St, Boone, IA 50036	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-19	Joel Waltz	joel@cuttingedgeiowa.com	Boone	Boone	Iowa	Robert Simmons	Deb Ernst	Signed	(1) The employer does not elect the employers’ liability coverage.	Joel Waltz	joel@cuttingedgeiowa.com	Self	Boone	Boone	IA	Robert Simmons	Deb Ernst	Signed
1631	2023-05-09 10:13	Anonymous (not verified)	94.188.207.229	Steve Stratton	Proprietorship	208 SE 5th St Grimes, Iowa 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-01	Steve Stratton	deb@piciowa.com	Grimes	Polk	Iowa	Debra Stratton	Kenneth Stratton	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Stratton	deb@piciowa.com	self	Grimes	Polk	Iowa	Debra Stratton	Kenneth Stratton	Signed
1805	2023-08-17 10:00	Anonymous (not verified)	94.188.207.229	Polly Pattison Sewing LLC	Limited Liability Company	6917 New York Ave. Urbandale, IA 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-17	Polly Pattison	pollypattison@msn.com	Urbandale	Polk	IA	Lynn Niceswanger	Louise Anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Polly Pattison	pollypattison@msn.com	Same	Urbandale	Polk	Iowa	Lynn Niceswanger	Louise Anderson	Signed
1806	2023-08-17 11:37	Anonymous (not verified)	94.188.207.229	OKOBOJI TSHIRT CENTER LLC	Limited Liability Company	PO BOX 158 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.	2023-08-16	YACCOB SEBAN	PACIFIC513@YAHOO.COM	ARNOLDS PARK	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	YAACOB SEBAN	PACIFIC513@YAHOO.COM	SELF	ARNOLDS PARK	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
2216	2024-05-09 11:51	Anonymous (not verified)	94.188.207.229	Imhoff Innovations LLC	Limited Liability Company	108 Cherry Lane Riverside, IA 52327	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-09	Jediah Imhoff	jedimhoff@gmail.com	Riverside	IA	United States	Jordan Nisiewicz	Jordan Lyod	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Regional Recruiter	Kansas City	Johnson	MO	Jordan Lyod	Jediah Imhoff	Signed
1782	2023-08-04 08:04	Anonymous (not verified)	94.188.207.229	Matt Larson Construction	Limited Liability Company	1208 Hazel St. Pella, IA 50219	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-04	Matthew Mark Larson	larson-m@hotmail.com	Pella	Marion	IA	Brian Huddle	Jon E. Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Jon E. Miller	stmarypella@iowatelecom.net	Parish Secretary	Pella	IOWA	United States	Brian Huddle	Jon E. Miller	Signed
1851	2023-09-22 12:36	Anonymous (not verified)	94.188.207.229	MNM Construction	Proprietorship	3224 sw 12th place 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.	2023-09-22	craig allen mccormick	craigmccormick.6363@gmail.com	Des Moines	Iowa	Iowa	Tara Murphy	Kristie Hubbard	Signed	(1) The employer does not elect the employers’ liability coverage.	craig mccormick	craigmccormick.6363@gmail.com	self	Des Moines	Iowa	Iowa	Tara Murphy	Kristie Hubbard	Signed
1975	2024-01-04 15:42	Anonymous (not verified)	94.188.207.229	Blake S. Judisch Masonry LLC	Limited Liability Company	510 South Fulton St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-04	Blake Judisch	blakejudisch@gmail.com	Shell rock	Butler	IA	Kali Judisch	Terri Thomsen	Signed	(1) The employer does not elect the employers’ liability coverage.	Blake Judisch	blalejudisch@gmail.com	Owner	Shell rock	Butler	IA	Kali Judisch	Terri Thomsen	Signed
1687	2023-06-12 16:23	Anonymous (not verified)	94.188.207.229	Jose Manuel Sanchez Loreto	Proprietorship	108 North Hawthorn Drive Altoona, Iowa 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.	2023-06-12	Jose Manual Sanzhez Loreto	jjanna1226@gmail.com	Altoona	Polk	Iowa	Debra Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Manuel Sanchez Loreto	jjana1226@gmail.com	self	Altoona	Polk	Iowa	Debra Stratton	Kelly Denger	Signed
2123	2024-03-28 10:42	Anonymous (not verified)	94.188.207.229	J&J Masonry	Proprietorship	2519 Poppleton 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.	2024-03-28	Jose Marroquin	drakkarhr7@gmail.com	Omaha	Douglas	Nebraska	Drake Rapaich	Sunita Rapaich	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Marroquin	drakkarhr7@gmail.com	Self	Omaha	Douglas	Nebraska	Drake Rapaich	Sunita Rapaich	Signed
2188	2024-04-29 09:05	Anonymous (not verified)	94.188.207.229	General Lee Franklin	Proprietorship	820 Oak Street, Burlington, IA 52601	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-25	General Lee Franklin	gleef1966@gmail.com	Burlington	Des Moines	Iowa	Cheryl Ross	Larry Rheinschmidt	Signed	(1) The employer does not elect the employers’ liability coverage.	General Lee Franklin	gleef1966@gmail.com	owner	Burlington	Des Moines	Iowa	Cheryl Ross	Larry Rheinschmidt	Signed
2052	2024-02-22 07:37	Anonymous (not verified)	94.188.207.229	Noahs Ark Flooring	Proprietorship	6212 se 2nd st 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.	2024-02-22	Noah James Daggett	daggettnoah365@gmail.com	Des moines	Polk	United States	Malichi Cerrato	Austin tolson	Signed	(1) The employer does not elect the employers’ liability coverage.	Noah James Daggett	daggettnoah365@gmail.com	Self	Des moines	IA	United States	Malichi Cerrato	Austin tolson	Signed
1497	2023-03-07 07:37	Anonymous (not verified)	94.188.207.229	Holzworth Land Company	Limited Liability Company	1730 All State Ct Suite 100 West Des Moines, IA 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2023-03-07	Victor Holzworth	holzconstruction@gmail.com	West Des Moines	Polk	Iowa	Reid Tamisiea	Mariah Burgett	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Victor Holzworth	holzconstruction@gmail.com	Owner	West Des Moines	Polk	iowa	Reid Tamisea	Mariah Burgett	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
2175	2024-04-24 09:14	Anonymous (not verified)	94.188.207.229	John Sapp	Proprietorship	2120 South Main Street Burlington, IA52601	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-23	John Curtis Sapp Jr.	jbuddysapp@gmail.com	Burlington	Des Moines	Iowa	Cheryl Ross	Larry Rheinschmidt	Signed	(1) The employer does not elect the employers’ liability coverage.	John C. Sapp Jr.	jbuddysapp@gmail.com	owner	Burlington	Des Moines	Iowa	Cheryl Ross	Larry Rheinschmidt	Signed
2032	2024-02-07 11:05	Anonymous (not verified)	94.188.207.229	NEIL MARTENS	Proprietorship	527 3RD STREET, SOUTH, ALBERT CITY, IA 50510	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-07	NEIL THIESSEN MARTENS	pkmmartens@hotmail.com	ALBERT CITY	BUENA VISTA	IOWA	JOHN CLARENCE OLERICH	ROBERT EUGENE BELT	Signed	(1) The employer does not elect the employers’ liability coverage.	NEIL MARTENS	pkmmartens@hotmail.com	SELF	ALBERT CITY	BUENA VISTA	IOWA	JOHN CLARENCE OLERICH	ROBERT EUGENE BELT	Signed
1735	2023-07-11 08:28	Anonymous (not verified)	94.188.207.229	LBN LLC	Limited Liability Company	1930 se 14th Des Moines Iowa 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-11	Gary Fatino	fatinomarketinggroup@yahoo.com	Des Moines	polk	Iowa	Liana Fatino	Gary Fatino	Signed	(1) The employer does not elect the employers’ liability coverage.	Gary Fatino	fatinomarketinggroup@yahoo.com	owner	des moines	polk	iowa	liana fatino	gary fatino	Signed
2130	2024-04-02 09:11	Anonymous (not verified)	94.188.207.229	Caliz Stone Services LLC	Limited Liability Company	1715 E 21st 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.	2024-04-02	Marvin Lopez	marvincaliz843@gmail.com	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Marvin Lopez	marvincaliz843@gmail.com	Self	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed
1715	2023-06-28 09:48	Anonymous (not verified)	94.188.207.229	Charles westbrook	Limited Liability Company	2374 31st a Moline	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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.	2023-06-28	Charles Micheal westbrook	Westbrook.69.mw@gmail.com	Moline	USA	Illinois	Taylor Davis	N/a	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Charles Micheal Westbrook	Westbrook.69.mw@gmail.com	Gf	Moline	IL	United States	Taylor davis	N/a	Signed
1767	2023-07-28 14:31	Anonymous (not verified)	94.188.207.229	Kleckner Backhoe Service	Proprietorship	1302 S 1st St, Osage, IA 50461	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-28	Tracy S Kleckner	terridkleckner@hotmail.com	Osage	Mitchell	Iowa	Robin Tabbert	Jeannie Lemke	Signed	(1) The employer does not elect the employers’ liability coverage.	L R Falk Construction Co	jeannie@lrfalk.com	Dump Truck Hauler	Osage	Mitchell	Iowa	Robin Tabbert	Jeannie Lemke	Signed
2071	2024-03-01 11:08	Anonymous (not verified)	94.188.207.229	Level92 Screen Printing LLC	Limited Liability Company	2500 W 2nd Ave Ste 10, Indianola, IA 50125	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-01	Alison Vice	orders@level92.com	Indianola	Warren	IA	Jake Vice	Grant Darrah	Signed	(1) The employer does not elect the employers’ liability coverage.	Alison Vice	orders@level92.com	Partner	Indianola	Warren	IA	Jake Vice	Grant Darrah	Signed
1521	2023-03-16 14:26	Anonymous (not verified)	94.188.207.229	Mmk electric	Partnership	4515 84th st Urbandale 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.	2023-03-16	Elijah dale kain	mmk.iowa@gmail.com	West Des moines	Polk	Iowa	Travis Lee miller	Marshall Logan McKay	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Lee miller	mmk.iowa@gmail.com	Owner	Urbandale	Polk	Iowa	Travis Lee miller	Marshall Logan mckay	Signed
1939	2023-12-05 14:32	Anonymous (not verified)	94.188.207.229	PJ Trucking Unlimited LLC	Limited Liability Company	2617 380th 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.	2023-12-05	Peggy Jensen	pegandhalj@gmail.com	Farragut	US	IA	Darlene	Julie Ann Marshsll	Signed	(1) The employer does not elect the employers’ liability coverage.	Peggy Jensen	pegandhalj@gmail.com	self	Farragut	US	IA	Darlene Carpenter	Julie Marshall	Signed
2076	2024-03-05 22:38	Anonymous (not verified)	94.188.207.229	Steve Roland Trucking LLC	Limited Liability Company	2141 Wadsley Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-05	Steve Roland	roland.farms@yahoo.com	Sac City	Sac	Iowa	Caylee Hoffard	Kristen Wirtjers	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Roland	roland.farms@yahoo.com	Owner/Member	Sac City	Sac	Iowa	Caylee Hoffard	Kristen Wirtjers	Signed
2210	2024-05-07 19:15	Anonymous (not verified)	94.188.207.229	Greenelectric	Proprietorship	407 Drury Lane	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-07	Harold Carr	handbcarr@hotmail.com	Legrad	Iowa	Iowa	Harold Dale Carr	Harold Dale Carr	Signed	(1) The employer does not elect the employers’ liability coverage.	Harold Carr	handbcarr@hotmail.com	I am the owner	Legrad	Iowa	Iowa	Harold Dale Carr	Harold Dale Carr	Signed
1505	2023-03-07 23:14	Anonymous (not verified)	94.188.207.229	Harbinger Consultants LLC	Limited Liability Company	2333 SW Plaza Pkwy, #324, Ankeny, IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-06	Joseph French	joey@harbinger.finance	Ankeny	Polk	Iowa	Sawyer Mueller	Kenneth French	Signed	(1) The employer does not elect the employers’ liability coverage.	Joseph French	joey@harbinger.finance	Principal	Ankeny	Polk	Iowa	Sawyer Mueller	Kenneth French	Signed
1860	2023-10-04 14:31	Anonymous (not verified)	94.188.207.229	Raymond Osbon	Proprietorship	1634 Park Towne LN NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-04	Raymond Earl Osbon	rozbon999@gmail.com	Cedar Rapids	Linn	Iowa	Brandon Gibbs	Jamie Fisher	Signed	(1) The employer does not elect the employers’ liability coverage.	Raymond Earl Osbon	rozbon999@gmail.com	Myself	Cedar Rapids	Linn	Iowa	Brandon Gibbs	Jamie Fisher	Signed
2027	2024-02-07 09:24	Anonymous (not verified)	94.188.207.228	RB SIDING	Proprietorship	P.O. BOX 2034, 310 370TH STREET, LAKE VIEW, IOWA 51450	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-07	ROBERT BELT	bridgetbelt1971@outlook.com	SELF	SAC	IOWA	JOHN CLARENCE OLERICH	NEIL THIESSEN MARTENS	Signed	(1) The employer does not elect the employers’ liability coverage.	ROBERT EUGENE BELT	bridgetbelt1971@outlook.com	SELF	LAKE VIEW	SAC	IOWA	JOHN CLARENCE OLERICH	NEIL THIESSEN MARTENS	Signed
2002	2024-01-26 17:00	Anonymous (not verified)	94.188.207.228	Legacy Group Consulting	Limited Liability Company	3721 Coppermill 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.	(1) I am not electing the employers’ liability coverage.	2024-01-26	John A Scott	legacygrpconsulting@gmail.com	Cedar Rapids	Linn	IA	Barbara Scott	Robert Moore	Signed	(1) The employer does not elect the employers’ liability coverage.	John A Scott	legacygrpconsulting@gmail.com	Owner	Cedar Rapids	Linn	IA	Barbara Scott	Robert Moore	Signed
1769	2023-07-31 11:23	Anonymous (not verified)	94.188.207.228	PSI LLC	Limited Liability Company	2765 N Center Point Rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-31	Esteici Reyes	stacy0979@gmail.com	Cedar Rapids	Linn	IA	Jeffrey Ventura	Eduardo Contreras	Signed	(1) The employer does not elect the employers’ liability coverage.	Esteici Reyes	stacy0979@gmail.com	Owner	Cedar Rapids	Linn	IA	Jeffrey Ventura	Eduardo Contreras	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
1815	2023-08-23 14:16	Anonymous (not verified)	94.188.207.228	JP Distribution, LLC	Limited Liability Company	3738 Pine Rdg NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-23	Jared Prelle	jpdist2014@gmail.com	North Liberty	IA	United States	Linda Stien	Dawn Franck	Signed	(1) The employer does not elect the employers’ liability coverage.	Jared Prelle	jpdist2014@gmail.com	Owner	North Liberty	Johnson	IA	Linda Stien	Dawn Franck	Signed
1721	2023-07-06 08:19	Anonymous (not verified)	94.188.207.228	Bradford Alexander Carr	Proprietorship	3349 Southgate Ct SW Ste 101	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-06	Bradford Alexander Carr	alex.carr@thrivent.com	Coralville	Johnson	Iowa	Gaylon Heetland	David King	Signed	(1) The employer does not elect the employers’ liability coverage.	Bradford Alexander Carr	alex.carr@thrivent.com	Self	Coralville	Johnson	Iowa	Gaylon Heetland	David King	Signed
1877	2023-10-23 15:49	Anonymous (not verified)	94.188.207.228	Craig Michael Wilson	Proprietorship	24538 118th Street, Columbus Junction, IA 52738	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-16	Craig Michael Wilson	tripod109@hotmail.com	Columbus Junction	Louisa	IA	Brenda Wilson	Ruger Dean	Signed	(1) The employer does not elect the employers’ liability coverage.	Craig Michael Wilson	tripod109@hotmail.com	Self	Columbus Junction	Louisa	IA	Brenda Wilson	Ruger Dean	Signed
1849	2023-09-19 14:57	Anonymous (not verified)	94.188.207.228	Iowa painting solutions llc	Limited Liability Company	2500 pleasant st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-19	Patricia Davalos	iowapaintingsolutionsllc@gmail.com	Des Moines	Polk	Iowa	Javier Rascon	Angel Perez	Signed	(1) The employer does not elect the employers’ liability coverage.	Iowa painting solutions llc	iowapaintingsolutionsllc@gmail.com	Owner	Des Moines	Polk	Iowa	Javier Rascon	Angel Perez	Signed
1531	2023-03-24 08:40	Anonymous (not verified)	94.188.207.228	Schneiter Insurance and Financial Solutions	Limited Liability Company	900 E 3RD ST	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-01	Jackie Schneiter	grlschneiter@gmail.com	MONTICELLO	IA	United States	Ronald Schneiter	Reagan Schneiter	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacqueline Schneiter	jackie@we78ins.com	owner	ANAMOSA	JONES	IOWA	RONALD SCHNEITER	REAGAN SCHNEITER	Signed
1688	2023-06-13 09:29	Anonymous (not verified)	94.188.207.228	Ron Burbach	Proprietorship	7760 commerce park Dubuque Iowa 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.	2023-06-13	Ronald V Burbach	allgreenron@msn.com	Dubuque	Dubuqie	Iowa	Mia Burnach	Jerry david	Signed	(1) The employer does not elect the employers’ liability coverage.	Ronald V Burbach	allgreenron@man.com	Same	Dubuque	Dubuque	Iowa	Mia F Burbach	Jerry David	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
1557	2023-04-05 20:42	Anonymous (not verified)	94.188.207.228	Nava lawn care and junk hauling	Limited Liability Company	220 2nd Street West Des Moines Iowa 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-05	Joan Nava Becerril	jnb.2499@gmail.com	West Des Moines	IA	United States	Aylin Silva Garcia	Arjan Silva	Signed	(1) The employer does not elect the employers’ liability coverage.	Joan Nava Becerril	info@navalawnandjunk.com	OWNER	West Des Moines	IA	United States	Aylin Silva Garcia	Arjan Silva	Signed
1625	2023-05-04 14:07	Anonymous (not verified)	94.188.207.228	Extreme Repair, LLC	Limited Liability Company	300 North Carthage St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-04	Tony Cleveland	extremerepair1@yahoo.com	EXIRA, IA	Audubon	United States	Katherine Cleveland	Isaac Kommes	Signed	(1) The employer does not elect the employers’ liability coverage.	Extreme Repai,r LLC	extremerepair1@yahoo.com	Self	EXIRA, IA	Audubon	United States	Katherine Cleveland	Isaac Kommes	Signed
1701	2023-06-22 15:03	Anonymous (not verified)	94.188.207.228	Midwest Teleworks	Limited Liability Company	1341 Cachelin Dr Carter Lake IA 51510	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	James Trotter	trotterwizard@gmail.com	Carter Lake	Pottawattamie	IA	Shelby Schultz	Elora Trotter	Signed	(1) The employer does not elect the employers’ liability coverage.	James Trotter	trotterwizard@gmail.com	Owner	Carter Lake	Pottawattamie	IA	Shelby Schultz	Elora Trotter	Signed
1909	2023-11-15 12:27	Anonymous (not verified)	94.188.207.228	CHAR-LES BUILDINGS LLC	Limited Liability Company	14633 7TH AVE NW, ANDOVER MN 55304	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-15	JOHNNY CHAVEZ CHAVEZ	charlychavez151@gmail.com	ANDOVER	ANOKA	MINNESOTA	ALEIDA LEE	DANY JIMBO	Signed	(1) The employer does not elect the employers’ liability coverage.	JOHNNY CHAVEZ CHAVEZ	charlychavez151@gmail.com	OWNER	ANDOVER	ANOKA	MINNESOTA	ALEIDA LEE	DANY JIMBO	Signed
1742	2023-07-12 12:43	Anonymous (not verified)	94.188.207.228	Old Glory Home Improvements LLC	Limited Liability Company	117 E Church st, Panora, 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.	2023-07-12	Laden Binjiman McDonald	mcdonaldladen@gmail.com	Waukee	Dallas	Iowa	Tina McDonald	Matt McDonald	Signed	(1) The employer does not elect the employers’ liability coverage.	Northwest Registered Agent	bmartin@frannet.com	Employer	Panora	Guthrie	Iowa	Tina McDonald	Matt McDonald	Signed
2057	2024-02-26 16:17	Anonymous (not verified)	94.188.207.228	Pedro Salazar Trejo	Proprietorship	1116 18th Ave SW Cedar Rapids IA 52402	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-26	Pedro Salazar Trejo	pedrosalazart@icolud.com	Cedar rapids	Linn County	IA	Carlos Izaguirre	Omar Trejo	Signed	(1) The employer does not elect the employers’ liability coverage.	Martiniano Germán Maldonado	maldonadomartiniano675@gmail.com	Employee	Cedar rapids	Linn County	Iowa	Carlos Izaguirre	Omar Trejo	Signed
1675	2023-06-02 09:37	Anonymous (not verified)	94.188.207.228	Kacena Family Tree Farm Inc	Partnership	2510 55th St., Vinton, IA 52349	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-01	Kevin Kacena	kacenafarms.alyce@gmail.com	Vinton	Benton	Iowa	Ashlyn J. Christianson	Angie McFarland	Signed	(1) The employer does not elect the employers’ liability coverage.	Alyce Lynch	ashlyn@3riversins.net	25% Owner - President	Vinton	Benton	Iowa	Ashlyn J. Christianson	Angie McFarland	Signed
1910	2023-11-15 13:06	Anonymous (not verified)	94.188.207.228	RODRIGUEZ ENTERPRISES III INC	Limited Liability Company	905 W US HIGHWAY 30 CARROLL IA 51401	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-14	MAURO RODRIGUEZ	mauro15o1@hotmail.com	CARROLL	CARROLL	IOWA	GONZALO MUNOZ	SILVIA CHAVEZ	Signed	(1) The employer does not elect the employers’ liability coverage.	MAURO RODRIGUEZ	mauro15o1@hotmail.com	OWNER	CARROLL	CARROLL	IA	GONZALO MUNOZ	SILVIA CHAVEZ	Signed
1673	2023-06-02 09:30	Anonymous (not verified)	94.188.207.228	Kacena Family Tree Farm Inc	Partnership	2510 55th St., Vinton, IA 52349	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-01	Alyce Lynch	kacenafarms.alyce@gmail.com	Vinton	Benton	Iowa	Ashlyn J. Christianson	Angie McFarland	Signed	(1) The employer does not elect the employers’ liability coverage.	Alyce Lynch	ashlyn@3riversins.net	25% Owner - President	Vinton	Benton	Iowa	Ashlyn J. Christianson	Angie McFarland	Signed
1829	2023-09-06 16:21	Anonymous (not verified)	94.188.207.228	JC Electric, LLC	Limited Liability Company	205 South Clinton St., Apt 4, Albia, IA 52531	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-05	John Coady	jcelectric.john@gmail.com	Albia	IA	United States	Todd Ryan	Jer McAnich	Signed	(1) The employer does not elect the employers’ liability coverage.	John Coady	jcelectric.john@gmail.com	Self	Albia	Monroe	IA	Todd Ryan	Jer McAnich	Signed
1933	2023-12-01 20:29	Anonymous (not verified)	94.188.207.228	Wasabi Johnston LLC	Limited Liability Company	5106 155th Street, Urbandale, IA 50323	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-01	Yean Ching Sue	soamie@hotmail.com	Urbandale	Dallas	Iowa	Enjin Zheng	Wen Zheng	Signed	(1) The employer does not elect the employers’ liability coverage.	Yean Ching Sue	soamie@hotmail.com	Owner	Urbandale	Dallas	Iowa	Enjin Zheng	Wen Zheng	Signed
2219	2024-05-10 10:20	Anonymous (not verified)	94.188.207.228	Froyo To Go, LLC	Limited Liability Company	909 4th Ave. South, Denison, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-10	Derek Lambert	drdereklambert@gmail.com	Denison	Crawford	Iowa	Maria Sandoval	Nahomy Fernandez Alvarado	Signed	(1) The employer does not elect the employers’ liability coverage.	Trevis Beeck	trevis.beeck.u0ms@statefarm.com	I am the State Farm Agent who is submitting the Business Policy	Denison	Crawford	Iowa	Maria Sandoval	Nahomy Fernandez Alvarado	Signed
1736	2023-07-11 08:30	Anonymous (not verified)	94.188.207.228	Scornos Waukee LLC	Limited Liability Company	286 w hickman rd waukee iowa 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-11	Liana Fatino	lfatino@yahoo.com	des moines	polk	iowa	Liana Fatino	Gary Fatino	Signed	(1) The employer does not elect the employers’ liability coverage.	Liana Fatino	lfatino@yahoo.com	owner	des moines	polk	IOWA	Liana Fatino	Gary Fatino	Signed
2012	2024-01-31 10:38	Anonymous (not verified)	94.188.207.228	Mathew Soulis	Proprietorship	618 Boston Drive, Davenport, IA 52806	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-31	Mathew Soulis	mathew.soulis@gmail.com	Davenport	Scott	IA	Jordan Nisiewicz	Cody Dunbar	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	JNisiewicz@leafhome.com	Recruiter	Kansas City	Johnson	MO	Cody Dunbar	Monica Acosta	Signed
1977	2024-01-05 13:25	Anonymous (not verified)	94.188.207.228	BOYOK BUILDS, LLC	Limited Liability Company	25395 140TH ST, 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.	2024-01-04	VITALE BOYOK	BOYOK68@GMAIL.COM	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	VITALE BOYOK	BOYOK68@GMAIL.COM	SELF	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	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
1873	2023-10-20 09:25	Anonymous (not verified)	94.188.207.228	GC Hauling LLC	Limited Liability Company	310 North 18th Street, 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.	2023-10-20	Garrett Joseph Claerhout	gjclaerhout@hotmail.com	INDIANOLA	IA	IA	Kirsten Claerhout	Jay Claerhout	Signed	(1) The employer does not elect the employers’ liability coverage.	Garrett Joseph Claerhout	gjclaerhout@hotmail.com	Same Person	INDIANOLA	IA	IA	Kirsten Claerhout	Jay Claerhout	Signed
2203	2024-05-06 12:44	Anonymous (not verified)	94.188.207.228	Cma landimprovments	Limited Liability Company	530 50th pleasantville	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-06	Cody authier	cauthier85@gmail.com	Pleasantville	Marion	Iowa	Melissa authier	Valerie vanhelten	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody authier	cauthier85@gmail.com	Self	Pleasantville	Marion	Iowa	Melissa authier	Valerie vanhelten	Signed
1840	2023-09-14 13:48	Anonymous (not verified)	94.188.207.228	L.R. Construction, LLC	Limited Liability Company	1564 110th Street, Hazleton, IA 50641	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-23	Levi R Raber	amish@amish.com	Hazleton	Buchanan	Iowa	Mary Ann Raber	Daniel Raber	Signed	(1) The employer does not elect the employers’ liability coverage.	Levi R Raber	amish@amish.com	self	Hazleton	BUCHANAN	Iowa	Mary Ann Raber	Daniel Raber	Signed
2028	2024-02-07 09:41	Anonymous (not verified)	94.188.207.228	J & J SIDING	Proprietorship	214 6TH STREET, P.O. BOX 482, LAKE VIEW, IOWA 51450	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-07	JOHN CLARENCE OLERICH	bigo@netins.net	LAKE VIEW	SAC	IOWA	ROBERT EUGENE BELT	NEIL THIESSEN MARTENS	Signed	(1) The employer does not elect the employers’ liability coverage.	JOHN CLARENCE OLERICH	bigo@netins.net	SELF	LAKE VIEW	SAC	IOWA	ROBERT EUGENE BELT	NEIL THIESSEN MARTENS	Signed
2199	2024-05-03 13:27	Anonymous (not verified)	94.188.207.228	Polar Delights LLC DBA Twists Ice Cream	Limited Liability Company	110 S 9th Ave Eldridge IA 52748	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-03	Anna Kokity	amkokity@gmail.com	Moline	Rock Island	IL	Ashley Schwien	Kasey Lange	Signed	(1) The employer does not elect the employers’ liability coverage.	Anna Kokity	amkokity@gmail.com	self	Moline	Rock Island	IL	Ashley Schwien	Kasey Lange	Signed
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
1708	2023-06-25 15:10	Anonymous (not verified)	94.188.207.228	Lopez concrete	Limited Liability Company	2009 otley ave perry Ia 50220	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-25	Erick Lopez	lopez1concrete@gmail.com	Perry	Dallas	IA	Ever tobar.	Elba alejandro	Signed	(1) The employer does not elect the employers’ liability coverage.	Erick lopez	lopez1concreto@gmail.com	Owner	Perry	Dallas	IA	Ever tobar	Elba alejandro	Signed
1692	2023-06-15 15:20	Anonymous (not verified)	94.188.207.228	Javier Rodriguez	Proprietorship	1512 18th St Des Moines, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-14	Javier A Rodriguez	R.Javier14@gmail.com	Des Moines	Polk	Iowa	Kelly Denger	Debra Stratton	Signed	(1) The employer does not elect the employers’ liability coverage.	Javier A Rodriguez	R.Javier14@gmail.com	self	Des Moines	Polk	Iowa	Kelly Denger	Debra Stratton	Signed
1489	2023-02-28 16:06	Anonymous (not verified)	94.188.207.228	Nate's Tractor LLC	Limited Liability Company	11939 birch Ave Riceville, IA 50466	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-28	Nathan Fox	nate@natestractor.com	Riceville	Howard	Iowa	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Nathan Fox	nate@natestractor.com	Member	Riceville	Howard	Iowa	Chris Fye	Darrel Elsbernd	Signed
2060	2024-02-28 09:36	Anonymous (not verified)	94.188.207.228	BRANDON LEHNER	Proprietorship	308 SANFORD STREET ARCHER IA 51231	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-28	BRANDON LEHNER	BLEHNER302@GMAIL.COM	ARCHER	OBRIEN	IA	TAMI KLEIN	JOSEPH LORING	Signed	(1) The employer does not elect the employers’ liability coverage.	BRANDON LEHNER	BLEHNER302@GMAIL.COM	SELF	ARCHER	OBRIEN	IA	TAMI KLEIN	JOSEPH LORING	Signed
2168	2024-04-22 08:18	Anonymous (not verified)	94.188.207.228	Mattson's Floor Covering	Proprietorship	2073 Sandy Lane	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-22	Blaine Linn Mattson	tmatzan99@yahoo.com	Oquawka	Henderson	Illinois	Cheryl Ross	Larry Rheinschmidt	Signed	(1) The employer does not elect the employers’ liability coverage.	Blaine Mattson	tmatzan22@yahoo.com	owner	Oquawka	Henderson	Illinois	Cheryl Ross	Larry Rheinschmidt	Signed
1961	2023-12-16 12:22	Anonymous (not verified)	94.188.207.228	Randy Hove	Proprietorship	2376 370th St. Jewell. Iowa. 50130	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Randy Gordon Hove	mandrhove@gmail.com	Jewell	Hamilton	Iowa	Ryan Drzycimski	Casey Westling	Signed	(1) The employer does not elect the employers’ liability coverage.	Randy	mandrhove@gmail.com	Same	Same	Same	Same	Same	Same	Signed
2102	2024-03-18 10:56	Anonymous (not verified)	94.188.207.228	NBJ Construction LLC	Limited Liability Company	2536 Capitol Ave Des Moines IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-18	Byron Jose Hernandez Nunez	bjhernandez198807@gmail.com	Des Moines	Polk	Iowa	Nathan Miller	Greg Beck	Signed	(1) The employer does not elect the employers’ liability coverage.	NBJ Construction LLC	bjhernandez198807@gmail.com	Owner	Des Moines	Polk	Iowa	Nathan Miller	Greg Beck	Signed
1544	2023-03-29 16:52	Anonymous (not verified)	94.188.207.228	Live Wire Trucking	Limited Liability Company	109 E Marion Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-29	Joshua Allen Moore	livewiretruckingIA@gmail.com	Sigourney	Iowa	United States	Ethan Weber	Dylan Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua Allen Moore	livewiretruckingIA@gmail.com	Owner	Sigourney	Iowa	United States	Ethan David Weber	Dylan Jefferey Miller	Signed
1731	2023-07-10 11:12	Anonymous (not verified)	94.188.207.228	Romer & Associates LLC	Limited Liability Company	433 Thomas Avenue, Maquoketa, IA 52060	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-10	Clay K Romer	connellsupply@aol.com	Maquoketa	Jackson	IA	Susan Croatt	Dave Stockham	Signed	(1) The employer does not elect the employers’ liability coverage.	Clay K Romer	connellsupply@aol.com	Owner/same	Maquoketa	Jackson	IA	Susan Croatt	Dave Stockham	Signed
1883	2023-10-27 10:49	Anonymous (not verified)	94.188.207.228	Ron's SIding and Construction	Proprietorship	6097 26th 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.	2023-10-27	Ron Heggebo	heggebojessica@yahoo.com	Vinton	Benton	IA	Jessica Heggebo	Jessica Heggebo	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron Heggebo	heggebojessica@yahoo.com	Self	Vinton	Benton	IA	Jessica Heggebo	Jessica Heggebo	Signed
2133	2024-04-03 19:58	Anonymous (not verified)	94.188.207.228	Soto Stone LLC	Limited Liability Company	1071 mansfield Dr waukee iowa 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2024-04-03	Yesser Lenin Juarez Soto	sotostonellc95@gmail.com	waukee	Dallas	Iowa	Ashley Marie Francisco	Vincent Alexander Flores	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Yesser Lenin Juarez Soto	sotostonellc95@gmail.com	self	waukee	Dallas	Iowa	Ashley Marie Francisco	Vincent Alexander Flores	Signed
1890	2023-11-01 19:22	Anonymous (not verified)	94.188.207.228	JACK SCHADE	Proprietorship	911 Broad St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-01	jack allan schade	jackschade@yahoo.com	Plymouth	IA	IA	jack allan schade	jack allan schade	Signed	(1) The employer does not elect the employers’ liability coverage.	jack allan schade	jackschade@yahoo.com	self	Plymouth	IA	IA	jack allan schade	jack allan schade	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
1537	2023-03-27 13:21	Anonymous (not verified)	94.188.207.228	miller hybrids	Limited Liability Company	1213 Larch Ave, Kalona, IA 52247	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-01	Jeremy Wakerhauser	jwakerhauser@gmail.com	Sun Prairie	WI	United States	Jeremy Wakerhauser	Jeremy Wakerhauser	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeremy Wakerhauser	jwakerhauser@gmail.com	sole proprieter	Sun Prairie	WI	United States	Jeremy Wakerhauser	Jeremy Wakerhauser	Signed
1927	2023-11-29 13:13	Anonymous (not verified)	94.188.207.228	Yaardman landscaping llc	Limited Liability Company	51623 se seet cedar rapids iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-29	Adrian Pink	Mr.Pink1118@gmail.com	CEDAR RAPIDS	IA	United States	Andrea Parker	Kamar James	Signed	(1) The employer does not elect the employers’ liability coverage.	Adrian Pink	Mr.Pink1118@gmail.com	Owner	CEDAR RAPIDS	IA	United States	Andrea Parker	Kamar James	Signed
1809	2023-08-21 07:55	Anonymous (not verified)	94.188.207.228	Gonzalez Drywall LLC	Limited Liability Company	323 Friendhip St Apt 3, Iowa City, IA 52245	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-21	Leonel Angel Gonzalez	victorangel8373@gmail.com	Iowa City	Johnson	Iowa	Chris Hay	Brad Bower	Signed	(1) The employer does not elect the employers’ liability coverage.	Leonel Angel Gonzalez	victorangel8373@gmail.com	Self	Iowa City	Johnson	Iowa	Chris Hay	Brad Bower	Signed
1942	2023-12-06 13:45	Anonymous (not verified)	94.188.207.228	K&K Service	Limited Liability Company	6125 R57 Hwy 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.	2023-12-06	Keaton Klocko	kklocko30@aim.com	Indianola	Warren	Iowa	Kourtne Klocko	Mallory Metzger	Signed	(1) The employer does not elect the employers’ liability coverage.	Keaton Klocko	kklocko30@aim.com	Owner	Indianola	Warren	Iowa	Kourtne Klocko	Mallory Metzger	Signed
2128	2024-03-29 09:52	Anonymous (not verified)	94.188.207.228	Mason Quality and Sons LLC	Proprietorship	18921 Willow St Omaha Ne 68136	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-29	Joel Castillo	drake.centurion@gmail.com	Omaha	Douglas	Nebraska	Drake Rapaich	Sunita Rapaich	Signed	(1) The employer does not elect the employers’ liability coverage.	Joel Castillo	drake.centurion@gmail.com	self	Omaha	Douglas	Nebraska	Drake Rapaich	Sunita Rapaich	Signed
1620	2023-05-01 08:03	Anonymous (not verified)	94.188.207.228	Devon Willis	Proprietorship	401 West 1st Street, Mechanicsville, IA 52306, United States	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-01	Devon Willis	willisbaseball2@gmail.com	Mechanicsville, IA	Cedar	Iowa	Jordan Nisiewicz	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Missouri	Clay	Jordan Loyd	Robert Snyder	Signed
2078	2024-03-06 16:19	Anonymous (not verified)	94.188.207.228	Iowa's Gutter Specialist LLC	Limited Liability Company	221 4th St SE Hampton Iowa 50441	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-06	Dustin Halverson	dh42312695@gmail.com	Hampton	Iowa	United States	Levi Paine	Amy Hayes	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin Halverson	dh42312695@gmail.com	Owner	Hampton	Iowa	United States	Levi Paine	Amy Hayes	Signed
2158	2024-04-17 11:47	Anonymous (not verified)	94.188.207.228	Mildred Lopez	Proprietorship	214 1st Ave SW Hampton, Iowa 50441	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-17	Mildred Lopez Camacho	morrison.hpd@gmail.com	Hampton	Franklin	Iowa	Ixia Anduce	Mark Morrison	Signed	(1) The employer does not elect the employers’ liability coverage.	Mildred Lopez	morrison.hpd@gmail.com	Self	Hampton	Franklin	IOwa	Ixia Anduce	Mark Morrison	Signed
1903	2023-11-13 09:08	Anonymous (not verified)	94.188.207.228	Christopher Stone	Proprietorship	2427 S Taft Ave Apt #8	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-10	Christopher Stone	darrele@ciains.biz	Iowa	Cerro Gordo	IA	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher Stone	darrele@ciains.biz	self	Mason City	Cerro Gordo	Iowa	Chris Fye	Darrel Elsbernd	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
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
1940	2023-12-05 15:11	Anonymous (not verified)	94.188.207.227	David Sickels	Proprietorship	2221 Radcliffe drive s.w cedar rapids Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-05	David Sickels	davidasickels@gmail.com	Cedar rapids	Linn	Iowa	Chad Allen Taylor	Steven Thomas Dunn	Signed	(1) The employer does not elect the employers’ liability coverage.	David Allen Sickels	davidasickels@gmail.com	Self	Cedar Rapids	Linn	Iowa	Chad Allen Taylor	Steven Thomas Dunn	Signed
1800	2023-08-14 20:24	Anonymous (not verified)	94.188.207.227	Laven Snow Removal LLC	Limited Liability Company	413 SE 6th street 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.	2023-08-14	Myles John Laven	lavensnowremoval@gmail.com	Ankeny	Polk	Iowa	Megan Rose Nefzger	Mackale Joel Laven	Signed	(1) The employer does not elect the employers’ liability coverage.	Myles John Laven	lavensnowremoval@gmail.com	Owner	Ankeny	Polk	Iowa	Megan Rose Nefzger	Mackale Joel laven	Signed
1647	2023-05-15 14:11	Anonymous (not verified)	94.188.207.227	Innovators construction llc	Limited Liability Company	3234 180th St. Homestead, IA 52236	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-15	Guadalupe Ramirez	info@jmdrywallonline.com	Homestead	Iowa	Iowa	Itali Ramírez	Manuela Muñoz	Signed	(1) The employer does not elect the employers’ liability coverage.	Juan M Ramírez	info@jmdrywallonline.com	Owner/spouse	Homestead	Iowa	Iowa	Itali Ramírez	Manuela Muñoz	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
1816	2023-08-23 14:59	Anonymous (not verified)	94.188.207.227	CHRIS PIERCE CONSTRUCTION LLC	Proprietorship	500 N 8th StAkron, IA 5100	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-23	Chris Pierce	chrispierceconstructionllc@gmail.com	Akron	Plymouth	IA	Susan Geist	Paychex Insurance Agency	Signed	(1) The employer does not elect the employers’ liability coverage.	Susan Geist	sgeist@paychex.com	Insurance Agency	Rochester	Monroe	NY	Susan Geist	Paychex Insurance Agency	Signed
1778	2023-08-03 14:52	Anonymous (not verified)	94.188.207.227	Melvin A mineros	Limited Liability Company	6209 Windsor dr des moines IA 50312	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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.	2023-06-22	Melvin alexander mineros	minerosframing.llc@gmail.com	Des moines	Polk	IA	Orlando dominguez	Isaac salazar	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jaime leiva	jaime@boersmaninsurance.com	Agent	Des moines	Polk	IA	Narciso hidalgo	Balmore perez	Signed
1973	2024-01-02 17:05	Anonymous (not verified)	94.188.207.227	Diego Puente	Proprietorship	1420 north st, apt#3 Perry Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-02	Diego Puente Martinez	diegopuente0655@gmail.com	Perry	Dallas	Iowa	Jason Van Dyke	Ashley Heffernen	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Van Dyke	jvandyke@thermalshop.com	worker	Cedar Rapids	Iowa	United States	Jason Van Dyke	Ashley Heffernen	Signed
1496	2023-03-06 11:24	Anonymous (not verified)	94.188.207.227	Carrillo Drywall, LLC	Limited Liability Company	119 Marsh St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-06	Yesenia Carrillo	yesecarrillo84@gmail.com	Waterloo	IA	United States	Rene Carrillo Jr	Martha Basurto	Signed	(1) The employer does not elect the employers’ liability coverage.	Kyle Hildman	kyleh@sinnottagency.com	Insurance Agent	Waterloo	IA	United States	Rene Carrillo Jr	Martha Basurto	Signed
1624	2023-05-03 10:30	Anonymous (not verified)	94.188.207.227	Ryan Deymonaz	Proprietorship	2303 Kingsway 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.	2023-05-03	Ryan Deymonaz	ryan.deymonaz@gmail.com	Bettendorf	Iowa	United States	Ryan Deymonaz	Hannah Baker	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Deymonaz	ryan.deymonaz@gmail.com	Self	Bettendorf	Iowa	United States	Ryan Deymonaz	Hannah Baker	Signed
1509	2023-03-09 10:39	Anonymous (not verified)	94.188.207.227	Andres Barboza	Limited Liability Company	329 West 31 St South Sioux city ne 68776	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-09	Andres Barboza	barboza79@yahoo.com	South Sioux City	Nebraska	United States	Jaime Gutierrez	Gerardo ibarra	Signed	(1) The employer does not elect the employers’ liability coverage.	Andres Barboza	barboza79@yahoo.com	Owner	South Sioux City	Nebraska	United States	Jaime Gutierrez	Gerardo ibarra	Signed
1775	2023-08-03 09:37	Anonymous (not verified)	94.188.207.227	J j builder llc	Limited Liability Company	2307 richland dr 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.	2023-07-28	José Cruz Jasso balleza	jassoprimo03@icloud.com	Des moines	Polk	Iowa	Jaime Rodrigues	Mario ramos	Signed	(1) The employer does not elect the employers’ liability coverage.	Irving	iibarra@centroinsurance.com	Agent	Des moines	Polk	Iowa	Irving Ibarra	Jaime Rodrigues	Signed
1791	2023-08-08 15:22	Anonymous (not verified)	94.188.207.227	dutch meadows lawn care	Limited Liability Company	304 W 9TH ST. S.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-08	david nunnikhoven	djnunnik@iowatelecom.net	newton	Iowa	United States	david nunnikhoven	david nunnikhoven	Signed	(1) The employer does not elect the employers’ liability coverage.	david nunnikhoven	djnunnik@iowatelecom.net	owner	newton	Iowa	United States	david nunnikhoven	david nunnikhoven	Signed
2045	2024-02-15 10:26	Anonymous (not verified)	94.188.207.227	Francesco Martinez	Proprietorship	403th 7th Ave NW Clarion IA 50525	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-15	Francesco Martinez	Martinexfrancesco99@gmail.com	Clarion	Wright	Iowa	Jason W Helmers	Josh W Helmers	Signed	(1) The employer does not elect the employers’ liability coverage.	Francesco Martinez	martinezfrancesco99@gmail.com	Employer	Clarion	Wright	Iowa	Jason W Helmers	Josh W Helmers	Signed
1488	2023-02-28 14:04	Anonymous (not verified)	94.188.207.227	Scotts Side Work Plus	Limited Liability Company	304 Wilshire Blvd 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.	2023-02-28	Lansing Scott	scottssideworkplus@gmail.com	Windsor Heights	Iowa	United States	Collin scott	Austyn Scott	Signed	(1) The employer does not elect the employers’ liability coverage.	Lansing Scott	scottssideworkplus@gmail.com	owner	Windsor Heights	Iowa	United States	Austyn Scott	Tracy scott	Signed
1689	2023-06-13 19:55	Anonymous (not verified)	94.188.207.227	Gerardo Reyes-Lopez	Limited Liability Company	908 West 1st Street, Waterloo, IA ,50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-13	Gerardo Reyes-lopez	greyeslopez9@gmail.com	Waterloo	Black Hawk	Iowa	Guillermina Lopez	Bernardo Reyes	Signed	(1) The employer does not elect the employers’ liability coverage.	Denise Seitsinger	denise@harmsinsuranceagency.com	Insurance Agent	Sumner	Bremer	Iowa	Gerardo Reyes	Bernardo Reyes	Signed
2114	2024-03-25 18:18	Anonymous (not verified)	94.188.207.227	Lisa V Blessington	Proprietorship	411 S 10th Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-25	Lisa Varie Blessington	lblessington@yahoo.com	Sac City	Sac	IA	Jean Rexroat	Jennifer Tovar	Signed	(1) The employer does not elect the employers’ liability coverage.	Lisa Varie Blessington	lblessington@yahoo.com	Same	Sac City	Sac	IA	Jean Rexroat	Jennifer Tovar	Signed
2151	2024-04-15 14:42	Anonymous (not verified)	94.188.207.227	Jose Acuna	Proprietorship	1015 East Main Street, Belmond, IA 50421, 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.	2024-04-15	Jose Acuna	Joseacuna@gmail.com	Belmond, IA	Wright	Iowa	Jordan Loyd	Jordan Nisiewicz	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Johnson	Missouri	Jordan Loyd	Cody Dunbar	Signed
1914	2023-11-20 16:05	Anonymous (not verified)	94.188.207.227	Dark Horse Transport LLC	Limited Liability Company	301 Lincoln St, Brayton, IA 50042	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-20	James William Meese	bethany.dhtllc@gmail.com	Brayton	Audubon	Iowa	Hayley Meese-Cherry	Wyatt Jessen	Signed	(1) The employer does not elect the employers’ liability coverage.	James Wiliam Meese	bethany.dhtllc@gmail.com	Owner	Brayton	Audubon	Iowa	Hayley Meese-Cherry	Wyatt Jessen	Signed
1861	2023-10-05 10:14	Anonymous (not verified)	94.188.207.227	Charles von Maur	Proprietorship	18325 Robbins Road Pleasant Valley IA 52767	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-05	Charles von Maur	rlarsen@vonmaur.com	Pleasant Valley	Scott	IA	Robert L Larsen	Amanda Bratthauer	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert L Larsen	rlarsen@vonmaur.com	Outside consultant	east moline	Rock Island	IL	Josh Barnes	Amanda Bratthauer	Signed
2129	2024-04-01 14:16	Anonymous (not verified)	94.188.207.227	Des Moines Construction LLC	Limited Liability Company	6615 SE 3rd St Des Moines IA 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-01	Rodrigo Valdes	desmoinesconstructionllc@gmail.com	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Rodrigo Valdes	desmoinesconstructionllc@gmail.com	Self	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	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
1826	2023-08-30 16:38	Anonymous (not verified)	94.188.207.227	IOWA MOLD REMOVAL	Limited Liability Company	103 15TH ST SW, 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.	2023-08-30	RHETT OSELETTE	RHETT.OSELETTE@GMAIL.COM	CLIVE	DALLAS	IOWA	ELLA OSELETTE	MYA OSELETTE	Signed	(1) The employer does not elect the employers’ liability coverage.	KATIE BROWN	KATIE@IOWAMOLDREMOVAL.COM	EMPLOYER	ALTOONA	POLK	IOWA	MYA OSELETTE	ELLA OSELETTE	Signed
1898	2023-11-09 09:56	Anonymous (not verified)	94.188.207.227	RC Restoration LLC	Limited Liability Company	991 June Drive, 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.	(1) I am not electing the employers’ liability coverage.	2023-11-09	Luke Hoffmann	luke@rentcube.com	Dubuque	Dubuque	Iowa	Randi Taylor	Carla Martin	Signed	(1) The employer does not elect the employers’ liability coverage.	Luke Hoffman	luke@rentcube.com	Owner	Dubuque	Dubuque	IA	Randi Taylor	Carla Martin	Signed
1887	2023-10-31 15:57	Anonymous (not verified)	94.188.207.227	CEM BUSINESSES LLC	Limited Liability Company	608 evergreen cir nw Bondurant, IA 50035	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-31	Dustin Rudolph	dmrudo@gmail.com	Des Moines	Polk	Iowa	Raelynn Aicher	Cameron VanBuren	Signed	(1) The employer does not elect the employers’ liability coverage.	Dane McDonald	dane.mcdonald@stellar-solar.net	Self	Bondurant	Polk	Iowa	Raelynn Aicher	Cameron VanBuren	Signed
1984	2024-01-15 17:33	Anonymous (not verified)	94.188.207.227	Jay Wang	Limited Liability Company	8481 Birchwood Ct, Johnston	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-15	Jay Wang	jaywang@wasabidsm.com	Clive	US	IA	Yingna Zheng	Qiaoqiao Li	Signed	(1) The employer does not elect the employers’ liability coverage.	Jay Wang	jaywang@wasabidsm.com	Self	Clive	US	IA	Yingna Zheng	Qiaoqiao Li	Signed
2064	2024-02-29 11:53	Anonymous (not verified)	94.188.207.227	Quality Masonry LLC	Limited Liability Company	4121 14th 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.	2024-02-29	Wilian Nunez	williamnunez77@gmail.com	Des Moines	IOWA	United States	Drake Rapaich	Nathan Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Wilian Nunez	Williamnunez77@gmail.com	Self	Des Moines	Polk	IA	Drake Rapaich	Nathan Miller	Signed
1664	2023-05-25 13:18	Anonymous (not verified)	94.188.207.227	Jason Vreeman	Proprietorship	5571 170th St sibley 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.	2023-05-25	Jason Vreeman	jvreeman21@gmail.com	Sibley	Osceola	IA	Katie Vreeman	Jerry vreeman	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Vreeman	jvreeman21@gmail.com	Self	Sibley	Osceola	IA	Katie Vreeman	Jerry vreeman	Signed
2073	2024-03-04 15:51	Anonymous (not verified)	94.188.207.227	JACOB HANSON	Proprietorship	415 N 18TH 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.	2024-03-04	JACOB HANSON	HANSONONEBOY@GMAIL.COM	ESTHERVILLE	EMMET	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	JACOB HANSON	HANSONONEBOY@GMAIL.COM	SELF	ESTHERVILLE	EMMET	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1919	2023-11-21 14:11	Anonymous (not verified)	94.188.207.227	Refined Construction	Limited Liability Company	4148 Mattern 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.	2023-11-21	Dustin Martin	dudtin.martin106@gmail.com	Des Moines	Polk	IA	Kelsey Baldinelli	Brandi Martin	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin Martin	dustin.martin106@gmail.com	Sole officer	Des Moines	Polk	IA	Kelsey Baldinelli	Brandi Martin	Signed
2126	2024-03-29 09:35	Anonymous (not verified)	94.188.207.227	MPO Masonry	Proprietorship	5027 s 20th at apt 12 Omaha ne 68107	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-29	Mauricio Ortega	pallaresmauricio72@gmail.com	Omaha	Douglas	Nebraska	Drake Rapaich	Sunita Rapaich	Signed	(1) The employer does not elect the employers’ liability coverage.	Mauricio Ortega	pallaresmauricio72@gmail.com	Self	Omaha	Douglas	Nebraska	Drake Rapaich	Sunita Rapaich	Signed
1930	2023-12-01 10:20	Anonymous (not verified)	94.188.207.227	TriCounty Enterprises/ DeNeve Construction	Limited Liability Company	5527 Crane Lane NE Cedar Rapids,IA 52402	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-01	Rick Delayne Primmer	rdprimmerroofing@gmail.com	Walker	Linn	Iowa	Jerry Wiltsey	Robert Null	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Delayne Primmer	rdprimmerroofing@gmail.com	Worker	Walker	Iowa	Iowa	Jerry Wiltsey	Robert Null	Signed
1960	2023-12-16 11:58	Anonymous (not verified)	94.188.207.227	Landeros Framing	Proprietorship	2418 E 37th Ct	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-16	Francisco Javier Landeros Garcia	garcialanderosfranciscojavier@gmail.com	Des Moines	IA	IA	Mirna Ruby	Jose Gaytan	Signed	(1) The employer does not elect the employers’ liability coverage.	Francisco Javier Landeros Garcia	garcialanderosfranciscojavier@gmail.com	owner	Des Moines	IA	IA	Mirna Ruby	Jose Gaytan	Signed
2030	2024-02-07 10:10	Anonymous (not verified)	94.188.207.227	Jason Jacobs	Proprietorship	115 West 7th St., Suite 1W, Spencer, IA 51301	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-07	Jason Jacobs	jason.jacobs@thrivent.com	Spencer	Clay	Iowa	Brad Bernardy	Emily Jacobs	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Jacobs	jason.jacobs@thrivent.com	Self	Spencer	Clay	Iowa	Brad Bernardy	Emily Jacobs	Signed
2085	2024-03-08 15:22	Anonymous (not verified)	94.188.207.227	Laura Cook	Proprietorship	2213 SW White Birch Dr, Ankeny, IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-18	Laura Cook	jared.vincent@insurancestationinc.com	Ankeny	Polk	Iowa	Jared Vincent	Colton Horak	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Schreck	mark.schreck@insurancestationinc.com	Agent	Altoona	IA	IA	Jared Vincent	Colton Horack	Signed
1561	2023-04-10 07:35	Anonymous (not verified)	94.188.207.227	All season gutter	Limited Liability Company	1790 187th street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-10	Shane Harold schnittjer	allseasongutter@outlook.com	Webster city	Hamilton	Iowa	Andrea Rae schnittjer	Shane Ethan schnittjer	Signed	(1) The employer does not elect the employers’ liability coverage.	Shane Harold schnittjer	allseasongutter@outlook.com	Self	Webster City	Hamilton	Iowa	Andrea Rae schnittjer	Shane Ethan schnittjer	Signed
1963	2023-12-18 14:45	Anonymous (not verified)	94.188.207.227	Elite Excavation Services	Limited Liability Company	13335 Amber Rd X44 Anamosa Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-18	Dalton Starn	eliteexcavationservices97@gmail.com	Anamosa	Jones	Iowa	Chase miller	Nathan Decker	Signed	(1) The employer does not elect the employers’ liability coverage.	Dalton Starn	eliteexcavationservices97@gmail.com	Owner	Anamosa	Jones	Iowa	Chase miller	Nathan decker	Signed
2211	2024-05-08 12:39	Anonymous (not verified)	94.188.207.227	Barron Carpentry & Renovations LLC	Limited Liability Company	1925 E 29th 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.	2024-05-07	Guillermo Barron	barroncarpentry.renovations@gmail.com	Des Moines	POLK	IOWA	Abigail Hernandez Colima	Diane Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Registered Agents INC.	agent@iowaregisteredagent.com	Registered agent	Waterloo	Black Hawk	IOWA	Abigail Hernandez Colima	Diane Garcia	Signed
1899	2023-11-09 16:55	Anonymous (not verified)	94.188.207.227	Factory Services	Limited Liability Company	2444 Elm 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.	2023-11-09	Mark Farrell	markfa12@yahoo.com	Fort Dodge	Webster	Iowa	Heather Farrell	Karson Farrell	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Farrell	markfa12@yahoo.com	Owner	Fort Dodge	Webster	Iowa	Heather Farrell	Karson12	Signed
1954	2023-12-13 13:51	Anonymous (not verified)	94.188.207.227	Beeson Trucking LLC	Limited Liability Company	219 Tilden St Kingsley IA 51028	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-13	Jeremy Beeson	jeremy4k78@yahoo.com	Kingsley	Plymouth	IA	Katherine Weaver	Darla Robley	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeremy Beeson	jeremy4k78@yahoo.com	Self	Kingsley	Plymouth	IA	Katherine Weaver	Darla Robley	Signed
1613	2023-04-27 13:57	Anonymous (not verified)	94.188.207.227	Jacob's Ladder Construction	Proprietorship	406 10th 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.	2023-04-27	Jacob Willis	jwillis924@gmail.com	Dallas Center	IA	United States	Anibal Bonilla	Ed Willis	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob A Willis	jwillis924@gmail.com	Owner	Dallas Center	IA	United States	Anibal Bonilla	Ed Willis	Signed
1555	2023-04-05 08:03	Anonymous (not verified)	94.188.207.227	DK Motor Freight	Proprietorship	3621 Tyler Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-05	David Kirchner	dkirchner89@gmail.com	Hartley	Obrien	Iowa	Janna VanDonge	Chad Driesen	Signed	(1) The employer does not elect the employers’ liability coverage.	David Kirchner	dkirchner89@gmail.com	Self	Hartley	Iowa	United States	Janna VanDonge	Chad Driesen	Signed
1615	2023-04-27 17:42	Anonymous (not verified)	94.188.207.227	John Anthony Davis	Proprietorship	P.O. Box 2551 Mountain View, AR 72560	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-27	John Anthony Davis	turbinespacemonkey@yahoo.com	Mountain View	Stone	Arkansas	Vicki Lynne Ivey	Maggielyn Marie Paul	Signed	(1) The employer does not elect the employers’ liability coverage.	John Anthony Davis	turbinespacemonkey@yahoo.com	Proprietor	Mountain View	Stone	Arkansas	Vicki Lynne Ivey	Maggielyn Marie Paul	Signed
1504	2023-03-07 18:38	Anonymous (not verified)	94.188.207.227	Mathias Heating & Cooling	Limited Liability Company	1449 19th Pl West Des Moines, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-07	Justin Mathias	emathiasj@gmail.com	West Des Moines	Polk	Iowa	Jesse Parker	Jeff Boucher	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Mathias	emathiasj@gmail.com	Member	West Des Moines	Polk	Iowa	Jesse Parker	Jeff Boucher	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
1777	2023-08-03 14:21	Anonymous (not verified)	94.188.207.227	Mark Doty	Proprietorship	509 Parwood Circle, Huxley, IA 50124	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-03	Mark Doty	mdoty@dakotagrown.com	Huxley	Story	IA	Rebecca R Moeller	Jeffery F Vanasse	Signed	(1) The employer does not elect the employers’ liability coverage.	Rebecca R Moeller	Becky@northernlines.net	Agent	Fairmont	MN	United States	Rebecca R Moeller	Jeffery F Vanasse	Signed
1690	2023-06-13 20:01	Anonymous (not verified)	94.188.207.227	Gerardo Reyes-Lopez	Limited Liability Company	908 West 1st Street, Waterloo, Iowa, 50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-13	Gerardo Reyes-lopez	bernardo@reyesconstruct.com	Waterloo	IA	United States	Guillermina Lopez	Bernardo Reyes	Signed	(1) The employer does not elect the employers’ liability coverage.	Denise Seitsinger	denise@harmsinsuranceagency.com	Insurance Agent	Sumner	Bremer	Iowa	Gerardo Reyes	Bernardo Reyes	Signed
2205	2024-05-07 08:56	Anonymous (not verified)	94.188.207.227	MILLER CONSTRUCTION SIDING & WINDOWS, LLC	Limited Liability Company	3104 SW 26TH STREET, ANKENY, IA. 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-07	SCOTT MICHAEL DORAU	scott@millersidingandwindows.com	ANKENY	POLK	IOWA	ADAM BOGE	LANCE WEBSTER	Signed	(1) The employer does not elect the employers’ liability coverage.	SCOTT MICHAEL DORAU	scott@millersidingandwindows.com	OWNER	ANKENY	POLK	IOWA	ADAM BOGE	LANCE WEBSTER	Signed
2137	2024-04-05 10:28	Anonymous (not verified)	94.188.207.227	Innovationsgenc@gmail.com	Limited Liability Company	1134 20th Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-05	Juan carlos Soto Deanda	charlye2512penelope@gmail.com	East Moline	IL	United States	Deja Rivers	Eric Schwab	Signed	(1) The employer does not elect the employers’ liability coverage.	Juan carlos Soto Deanda	charlye2512penelope@gmail.com	Owner	East Moline	IL	United States	Deja Rivers	Eric Schwab	Signed
2135	2024-04-04 11:02	Anonymous (not verified)	94.188.207.227	Jonathan Warner	Proprietorship	420 16th Avenue, East Moline, IL 61244, 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.	2024-04-04	Jonathan Warner	bsguttersllc@gmail.com	East Moline, IL	Moline	Illinois	Jordan Nisiewicz	Cody Dunbar	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Johnson	MO	Jordan Loyd	Cody Dunbar	Signed
1510	2023-03-09 10:57	Anonymous (not verified)	94.188.207.226	Sawyer Eblen	Proprietorship	14411 293rd Ave NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-09	Sawyer Eblen	sawyer.eblen@gmail.com	Belgrade	MN	United States	Brandon Keller	Mitchell Vetsch	Signed	(1) The employer does not elect the employers’ liability coverage.	Sawyer Eblen	sawyer.eblen@gmail.com	Owner	Belgrade	MN	United States	Brandon Keller	Mitchell Vetsch	Signed
2146	2024-04-12 11:42	Anonymous (not verified)	94.188.207.226	Ken McGraw	Proprietorship	162 Green St Center Point IA 52213	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-12	Ken Mcgraw	kenmcgraw1974@gmail.com	Center Point	Linn	Iowa	Jenny Vaske	Bob Nissen	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Ashlock	brian@tricounty-iowa.com	General Manager	Cedar Rapids	Linn	Iowa	Bob Nissen	Jenny Vaske	Signed
2069	2024-03-01 09:55	Anonymous (not verified)	94.188.207.226	A-1 Stone LLC	Limited Liability Company	4308 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.	2024-03-01	Orlando Manuel Nunez Mejia	orlando20025@gmail.com	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Perla Patricia Nunez	nunezstone@gmail.com	Employee	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed
1956	2023-12-14 13:45	Anonymous (not verified)	94.188.207.226	Fey Concrete Inc	Proprietorship	307 East Judson St, Maquoketa, IA 52060	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Charles W Fey	chuckfey55@gmail.com	Maquoketa	Jackson	Iowa	Susan Croatt	Dave Stockham	Signed	(1) The employer does not elect the employers’ liability coverage.	Charles W Fey	chuckfey55@gmail.com	Owner/same	Maquoketa	Jackson	Iowa	Susan Croatt	Dave Stockham	Signed
2117	2024-03-27 10:38	Anonymous (not verified)	94.188.207.226	ALCON CONSTRUCTION LLC	Limited Liability Company	2613 GINDY DR, BELLEVUE, NE 68147	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-27	VALERIE OLONO	ALCONCONSTRUCTION2021@GMAIL.COM	BELLEVUE	SARPY	NEBRASKA	VICTOR H OLONO GANDARILLA	ALEXANDRA GUTIERREZ	Signed	(1) The employer does not elect the employers’ liability coverage.	VALERIE OLONO	ALCONCONSTRUCTION2021@GMAIL.COM	SELF	BELLEVUE	SARPY	NEBRASKA	VICTOR H OLONO GANDARILLA	ALEXANDRA GUTIERREZ	Signed
1667	2023-05-29 22:31	Anonymous (not verified)	94.188.207.226	All J Acres	Limited Liability Company	13522 120th Ave, Ottumwa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-26	Jonathan Bunt	jonbunt@gmail.com	Ottumwa	Wapello	IA	James Williamson	James Ash	Signed	(1) The employer does not elect the employers’ liability coverage.	Jonathan Bunt	jonbunt@gmail.com	Self	Ottumwa	Wapello	IA	James Williamson	James Ash	Signed
1902	2023-11-10 08:45	Anonymous (not verified)	94.188.207.226	Huff Construction LLC	Limited Liability Company	1309 Business 30 Sw, Mount Vernon, IA 52314	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-10	Jason Huff	huff.jasonm@gmail.com	Mount Vernon	IA	United States	Katie Huff	Van Huff	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Huff	huff.jasonm@gmail.com	Owner	Mount Vernon	IA	United States	Katie Huff	Van Huff	Signed
2160	2024-04-17 18:21	Anonymous (not verified)	94.188.207.226	QC Remodeling LLC	Limited Liability Company	421 West Broadway, Ste 302 Council Bluffs, IA 51503	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-17	Fernando Ibarra	ibarra_fernando@hotmail.com	Rock Island	Rock Island	Illinois	Paula Barria	Louis Valencia	Signed	(1) The employer does not elect the employers’ liability coverage.	Fernando Ibarra	ibarra_fernando@hotmail.com	Owner	Rock Island	Rock Island	Illinois	Paula Barria	Louis Valencia	Signed
2088	2024-03-12 10:44	Anonymous (not verified)	94.188.207.226	Elmer Henry Vicente Lopez	Proprietorship	1602 Court St Apt 2 Sioux City, IA 51105	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-01	Elmer Henry Vicente Lopez	vicenteelmer33@gmail.com	Sioux City	Woodbury	Iowa	Adrian Dominguez	Ronald Halverson	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron Halverson	ron@sppinsurance.com	independent contractor	Cherokee	Cherokee	IA	Elmer Henry Vicente Lopez	Ronald Halverson	Signed
2221	2024-05-13 09:26	Anonymous (not verified)	94.188.207.226	Chad matthews	Proprietorship	3000 Justin dr. Suite J	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2024-05-13	Chad matthews	kaceno2269@gmail.com	Urbandale	IA	United States	Sheri Frazier	Terry warren	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Chad Matthews	kaceno2269@gmail.com	None	Urbandale	IA	United States	Sheri Fraiser	Terry Warren	Signed
1953	2023-12-12 15:38	Anonymous (not verified)	94.188.207.226	Ryan Gideon	Proprietorship	9320 Elmcrest Dr 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.	2023-12-12	Ryan Gideon	rgid8403@gmail.com	Norwalk	Warren	IA	Jim Lane	Jim Lane	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Gideon	rgid8403@gmail.com	Owner	Norwalk	Warren	IA	jim Lane	Jim Lane	Signed
2200	2024-05-06 08:46	Anonymous (not verified)	94.188.207.226	Dominguez Construction LLC	Limited Liability Company	1680 East Emma Des Moines, IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-05	Ramon Dominguez	3memincolina@gmail.com	Des Moines	Polk	Iowa	Nathan Miller	Stacey Lazear	Signed	(1) The employer does not elect the employers’ liability coverage.	Ramon Dominquez	3memincolina@gmail.com	Owner	Des Moines	Polk	Iowa	Nathan Miller	Stacey Lazear	Signed
2036	2024-02-07 16:22	Anonymous (not verified)	94.188.207.226	JR CONSTRUCTION	Proprietorship	502 JOHNSON STREET, ALTA, IA 51002	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-07	JOHAN PETERS REIMER	reimerjohan16@gmail.com	ALTA	BUENA VISTA	IOWA	NEIL THIESSEN MARTENS	PETER KLASSEN MARTENS	Signed	(1) The employer does not elect the employers’ liability coverage.	JOHAN PETERS REIMER	reimerjohan16@gmail.com	SELF	ALTA	BUENA VISTA	IOWA	NEIL THIESSEN MARTENS	PETER KLASSEN MARTENS	Signed
1623	2023-05-02 14:09	Anonymous (not verified)	94.188.207.226	Leafhome Solutions LLC	Limited Liability Company	1595 Georgetown Road Hudson, Ohio 44236	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-02	Grant Anders Scott	G2designLLC@yahoo.com	Des Moines	Polk	Iowa	Katherine Scott	Brian Yurko	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Yurko	byurko@leafhome.com	Recruiter	Hudson	Summit	Ohio	Katherine Scott	Grant Scott	Signed
1889	2023-11-01 06:44	Anonymous (not verified)	94.188.207.226	Williams Hardwood Flooring LLC	Limited Liability Company	P.O. Box 22 Marion, Ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-01	Chad Everett William	williamshardwoodflooringllc@gmail.com	Anamosa	Jones	IA	Tara Williams	Sarah Williams	Signed	(1) The employer does not elect the employers’ liability coverage.	Chad E Williams	williamsharfwoodflooringllc@gmail.com	Me	Anamosa	Jones	IA	Tara Williams	Sarah Williams	Signed
2068	2024-03-01 09:53	Anonymous (not verified)	94.188.207.226	A-1 Stone LLC	Limited Liability Company	4308 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.	2024-03-01	Orlando Nunez	nunezstone@gmail.com	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Perla Patricia Nunez	nunezstone@gmail.com	Employee	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed
1506	2023-03-08 15:12	Anonymous (not verified)	94.188.207.226	Heritage Towing LLC	Limited Liability Company	404 Sherman Ave. Ackley Iowa 50601	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-08	Jeff Brass	heritagemotors17@yahoo.com	Ackley	Hardin	Iowa	Joellen Reynolds	Linzie Morris	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeff Brass	hertiagemotors17@yahoo.com	Member of LLC	Ackley	Hardin	Iowa	JoEllen Reynolds	Linzie Morris	Signed
2154	2024-04-16 08:05	Anonymous (not verified)	94.188.207.226	Lanz Pork Inc	Proprietorship	12905 N 1050th Road, Macomb, IL 61455	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-02	Andrew M Riggins	kellylanz1967@gmail.com	Macomb	IL	United States	Barb Coker	Scott Caspall	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew M Riggins	kellylanz1967@gmail.com	Self	Macomb	IL	United States	Barb Coker	Scott Caspall	Signed
2043	2024-02-13 13:38	Anonymous (not verified)	94.188.207.226	mannys handyman services	Limited Liability Company	3084 120th st cumming ia 50061	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-13	manuel v banegas	mannyshandymanservices.ia@gmail.com	cumming	3084 120th st	iowa	Adam Boge	Lance Webster	Signed	(1) The employer does not elect the employers’ liability coverage.	manuel v banegas	mannyshandymanservices.ia@gmail.com	self employeed	Cumming	Madison	Iowa	Adam Boge	Lance Webster	Signed
1515	2023-03-13 15:04	Anonymous (not verified)	94.188.207.226	Flint Hillman	Proprietorship	1019 E 17th St, APT 16, 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.	2023-03-13	Flint Hillman	flinthillman@gmail.com	Norwalk	Warren	Iowa	Tina Robinson	Paige Robinson	Signed	(1) The employer does not elect the employers’ liability coverage.	Flint Hillman	flinthillman@gmail.com	Self	Norwalk	Warren	Iowa	Tina Robinson	Paige Robinson	Signed
2201	2024-05-06 10:42	Anonymous (not verified)	94.188.207.226	Trent Hatlen	Proprietorship	1042 490th Street, Rembrandt, IA 50576	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-06	Trent Hatlen	trentgotti@yahoo.com	Rembrandt	Buena Vista	Iowa	Jared Brashears	Katie Gunkelman	Signed	(1) The employer does not elect the employers’ liability coverage.	Trent Hatlen	trentgotti@yahoo.com	Owner	Rembrandt	Buena Vista	Iowa	Jared Brashears	Katie Gunkelman	Signed
1922	2023-11-24 14:29	Anonymous (not verified)	94.188.207.226	Tommie Prince private contractor	Proprietorship	2320 Farwell Road, 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.	2023-12-01	Tommie Prince	amy@premierpayee.org	Des Moines	Polk	Iowa	Amy Meyer	Morgan Meyer	Signed	(1) The employer does not elect the employers’ liability coverage.	Tomme Prince private contractor	amy@premierpayee.org	Self	Des Moines	Polk	Iowa	Amy Meyer	Morgan Meyer	Signed
1804	2023-08-16 18:22	Anonymous (not verified)	94.188.207.226	Zach Moyle Masonry	Limited Liability Company	7222 Great River Rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-16	Zach Moyle	zmoylemasonry@gmail.com	Clermont	FAYETTE	FAYETTE	Brittney Loyd	Dave Moyle	Signed	(1) The employer does not elect the employers’ liability coverage.	Zach Moyle	zmoylemasonry@gmail.com	Self	Clermont	FAYETTE	FAYETTE	Brittney Loyd	Dave Moyle	Signed
2040	2024-02-08 10:35	Anonymous (not verified)	94.188.207.226	Storm Pro Solution	Limited Liability Company	1309 Coffeen Sheridan,wy 82801	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-08	Candis Henderson	Cneal@stormprosolution.com	Broadview	Chicago	Illinois	Chester Neal	Eric Henderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Candis Henderson	Cneal@stormprosolution.com	Self	Broadview	Chicago	Illinois	Chester neal	Eric Henderson	Signed
1493	2023-03-05 22:42	Anonymous (not verified)	94.188.207.226	Wyckoff Heating and Cooling	Proprietorship	95 hwy 5 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.	2023-03-05	Travis Keeney	knytrav@aol.com	carlisle	warren	iowa	James Ren	Troy Keeney	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Keeney	knytrav@aol.com	Subcontractor	carlisle	warren	iowa	James Ren	Troy Keeney	Signed
2187	2024-04-29 08:30	Anonymous (not verified)	94.188.207.226	Fran Stonework LLC	Limited Liability Company	1222 E Seneca Ave Apt 7, Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-29	Francisco Rodriguez Rios	panchito941@icloud.com	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Francisco Rodriguez Rios	panchito941@icloud.com	Self	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed
1848	2023-09-19 10:20	Anonymous (not verified)	94.188.207.226	Josh Woodworth	Proprietorship	16405 u.s. 67 milan il 61264	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-19	Josh woodworth	joshwoodworth84@live.com	milan	Rock island	Illinois	Cody dunbar	Jordan nisiewicz	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody dunbar	cdunbar@leaffilter.com	Install manager	moline	Rock island	illinois	Cody dunbar	Jordan nisiewic	Signed
1591	2023-04-21 13:59	Anonymous (not verified)	94.188.207.226	Self employed	Proprietorship	406 s main prairie city	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-21	Thomas Leo carroll	Tom.carroll66@gmail.com	Prairie city	Jasper	Iowa	Tina hellyer	Matt wenthie	Signed	(1) The employer does not elect the employers’ liability coverage.	Tom carroll	Tom.carroll66@gmail.com	Self	Prairie city	Jasper	Iowa	Tina hellyer	Matt whinthy	Signed
1670	2023-05-30 17:07	Anonymous (not verified)	94.188.207.226	Davis&Viteri LLC	Limited Liability Company	1125 Florida ave apt 519 Ames Iowa 50014	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-30	Christopher Viteri	davisviteri17@gmail.com	Johnston	Polk	Iowa	Labron davis	Marshalle Coleman	Signed	(1) The employer does not elect the employers’ liability coverage.	Marshalle coleman	marshalle.coleman@yahoo.con	Friend	Ames	Story	Iowa	Marshalle coleman	Labron davis	Signed
2207	2024-05-07 09:44	Anonymous (not verified)	94.188.207.226	Rodrimart brothers corp	Limited Liability Company	958 8th ave nw Altoona 50009	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-07	Enrique Rodriguez	carluto_1983@hotmail.com	Altoona	Polk	Iowa	Adan boge	Lonce wester	Signed	(1) The employer does not elect the employers’ liability coverage.	Enrique Rodriguez	carluto_1983@hotmail.com	President	Altoona	Polk	Iowa	Adan boge	Leans wester	Signed
2005	2024-01-29 08:50	Anonymous (not verified)	94.188.207.226	Laser Line Striping	Proprietorship	10572 320th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-29	Dean Weikert	d.lineuponline@yahoo.com	Ackley	Iowa	United States	Linda Weikert	Ca	Signed	(1) The employer does not elect the employers’ liability coverage.	Kain Helmke	d.lineuponline@yahoo.com	D.lineuponline@yahoo.com	Ackley	Butler	Iowa	Linda Weikert	Kain Helmke	Signed
1683	2023-06-09 07:11	Anonymous (not verified)	94.188.207.226	Daves Boys Moving and Hauling LLC	Limited Liability Company	264 Derbyshire Rd.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-09	Curtis Lane	Curtis@davesboys.com	Waterloo	Blackhawk County	IA	Shelley Caughron	Macray Caughron	Signed	(1) The employer does not elect the employers’ liability coverage.	Curtis Lane	Curtis@davesboys.com	Myself	Waterloo	Blackhawk	IA	Shelley Caughron	Macray Caughron	Signed
1734	2023-07-11 08:25	Anonymous (not verified)	94.188.207.226	LBN LLC	Limited Liability Company	1930 se 14th Des Moines Iowa 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-11	Liana Fatino	lfatino@yahoo.com	Des Moines	Polk	Iowa	Liana Fatino	Gary Fatino	Signed	(1) The employer does not elect the employers’ liability coverage.	Liana Fatino	lfatino@yahoo.com	owner	des moines	polk	Iowa	Liana Fatino	Gary Fatino	Signed
2072	2024-03-01 11:27	Anonymous (not verified)	94.188.207.226	SoldFast Real Estate L.L.C.	Limited Liability Company	5525 Meredith Drive Des Moines, Iowa 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-02	Darlyn Fructuoso	thejjscleaningllc@gmail.com	Des Moines	Polk	IA	Beatriz Musselman	Darlyn Fructuoso	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody Wilkinson	cody@soldfast.com	Contractor	Des Moine	Polk	IA	Beatriz Musselman	Darlyn Fructuoso	Signed
1944	2023-12-06 16:41	Anonymous (not verified)	94.188.207.226	Sell Now Iowa	Limited Liability Company	5525 Meredith Dr Suite B Des Moines, Iowa 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-06	Alejandro Bacano Rodriguez	alejandrobacanorodriguez@gmail.com	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Sale Now Iowa	team@sellnowiowa.com	None	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed
1832	2023-09-08 12:01	Anonymous (not verified)	94.188.207.226	GFORCE	Limited Liability Company	529 Anderson Street Jewell IA 50130	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-06	Scott Andrew Griffin	G6@q.com	Jewell	Hamilton	Iowa	Colten Abram Griffin	Hunter Austin Griffin	Signed	(1) The employer does not elect the employers’ liability coverage.	Colten Abram Griffin	G6@q.com	Partner	Ames	Story	Iowa	Hunter Austin Griffin	Scott Andrew Griffin	Signed
2009	2024-01-29 22:59	Anonymous (not verified)	94.188.207.226	Kimberly Ruby Reyes Victoriano	Proprietorship	1910 Eric 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.	2024-01-29	Kimberly Ruby Reyes Victoriano	InOnePieceDrywall@gmail.com	Waterloo	Black Hawk	Iowa	Juan Jose Victoriano Ramirez	Denir Billy Flores	Signed	(1) The employer does not elect the employers’ liability coverage.	Kimberly Ruby Reyes Victoriano	InOnePieceDrywall@gmail.com	Owner	Waterloo	Black Hawk	Iowa	Juan Jose Victoriano Ramirez	Fredy Perez Perez	Signed
1621	2023-05-01 15:53	Anonymous (not verified)	94.188.207.226	Hearing Health Care	Limited Liability Partnership	2519 S 16TH ST	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-01	Melissa Knoell	MELISSAKNOELL@YAHOO.COM	COUNCIL BLFS	IA	IA	Bruce Carol Johnk	Marcelyn Maureen Johnk	Signed	(1) The employer does not elect the employers’ liability coverage.	Melissa Knoell	melissaknoell@yahoo.com	self	Council Bluffs	Pottawattomi	IA	Bruce Carol Johnk	Marcelyn Maureen Johnk	Signed
1710	2023-06-26 16:10	Anonymous (not verified)	94.188.207.226	Adaptability Plus	Limited Liability Company	904 W 4th 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.	2023-06-26	Timothy Combs	timcombs@afiliowa.org	Waterloo	Iowa	United States	Teresa Tjaden	Mark Moser	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Moser	mpmmoser@gmail.com	PARTNER	WATERLOO	Black Hawk	Iowa	TERSEA TJADEN	TIM COMBS	Signed
1533	2023-03-25 10:24	Anonymous (not verified)	94.188.207.226	Doug Uridil	Proprietorship	616 16th Street NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-22	Doug Uridil	douguridil@gmail.com	Cedar Rapids	United States	IOWA	Heidi Vincent	Molly Coffman	Signed	(1) The employer does not elect the employers’ liability coverage.	Doug Uridil	douguridil@gmail.com	Self	Cedar Rapids	United status	IOWA	Heidi Vincent	Molly Kaufman	Signed
1773	2023-08-03 08:24	Anonymous (not verified)	94.188.207.226	LR Construction LLC	Limited Liability Company	1564 110th Street, Hazleton, IA 50641	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-23	Levi R Raber	leviraber@amish.com	Hazleton	Buchanan	Iowa	Mary Ann Reber	Daniel Raber	Signed	(1) The employer does not elect the employers’ liability coverage.	Levi R Raber	leviraber@amish.com	self	Hazleton	Buchanan	Iowa	Julie Schick	Kelly Matt	Signed
1967	2023-12-27 13:28	Anonymous (not verified)	94.188.207.225	Marvin Gingrich	Proprietorship	114641 Chariot Rd Elgin 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.	2022-02-25	Marvin Gingerich	darrele@ciains.biz	Elgin	Fayette	Iowa	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Marvin Gingerich	darrele@ciaisn.biz	Self	Elgin	Fayette	Iowa	Chris Fye	Darrel Elsbernd	Signed
1888	2023-10-31 15:59	Anonymous (not verified)	94.188.207.225	CEM Businesses LLC	Limited Liability Company	608 Evergreen Cir NW	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-31	Ryan Canales	ryancanales44@gmail.com	West Des Moines	Polk	Iowa	Raelynn Aicher	Cameron VanBuren	Signed	(1) The employer does not elect the employers’ liability coverage.	Dane McDonald	dane.mcdonald@stellar-solar.net	Self	Bondurant	Polk	Iowa	Raelynn Aicher	Cameron VanBuren	Signed
1862	2023-10-05 14:30	Anonymous (not verified)	94.188.207.225	J trinidad Garcia Ferrer	Proprietorship	3722 SE 14th St Apt 9 Des Moines, Iowa 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-01	J Trinidad Garcia Ferrer	deb@piciowa.com	Des Moines	Polk	Iowa	Deb Stratton	Martin Pinon	Signed	(1) The employer does not elect the employers’ liability coverage.	J trinidad Garcia Ferrer	deb@piciowa.com	self	Des Moines	Polk	IOwa	Deb Stratton	Martin Pinon	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
1997	2024-01-25 11:09	Anonymous (not verified)	94.188.207.225	Abstract Associates of Iowa Inc.	Proprietorship	822 Central Ave Ste 304 Fort Dodge, IA 50501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-21	Ted Hugghins	tjhugghins@abstractassociatesofiowa.com	Fort Dodge	Webster	Iowa	Mariah Ayala	Bennett O'Connor	Signed	(1) The employer does not elect the employers’ liability coverage.	Ted Hugghins	tjhugghins@abstractassociatesofiowa.com	President	Fort Dodge	Webster	IA	Mariah Ayala	Bennett O'Connor	Signed
1915	2023-11-21 04:06	Anonymous (not verified)	94.188.207.225	Advanced Foam Systems	Limited Liability Company	1378 Midway Ave Tripoli IA 50676	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-18	Randy Block	advancedfoamsystems@yahoo.com	Tripoli	Bremer	Iowa	Linda Block	Brady Block	Signed	(1) The employer does not elect the employers’ liability coverage.	Randy Block	advancedfoamsystems@yahoo.com	Me	Tripoli	Bremer	Iowa	Linda block	Brady block	Signed
1833	2023-09-08 13:39	Anonymous (not verified)	94.188.207.225	Superior painting & epoxy coatings llc	Limited Liability Company	4918 ne crestmoor ln	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-05	Anthony Negrete jr	superior.paint@hotmail.com	Ankeny	IA	United States	Stacey Marie stoecker	Anthony Negrete jr.	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony Negrete jr	superior.paint@hotmail.com	Spouse	Ankeny	IA	United States	Anthony Negrete jr	stacey marie Stoecker	Signed
1938	2023-12-05 11:54	Anonymous (not verified)	94.188.207.225	Genius automotive	Limited Liability Company	51623 se seet cedar rapids iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-05	Adrian Pink	Mr.Pink1118@gmail.com	CEDAR RAPIDS	IA	United States	Andrea Parker	Kamar james	Signed	(1) The employer does not elect the employers’ liability coverage.	Adrian Pink	Mr.Pink1118@gmail.com	None	CEDAR RAPIDS	IA	United States	Andrea Parker	Kamar James	Signed
1765	2023-07-27 14:27	Anonymous (not verified)	94.188.207.225	Midwest Systems	Proprietorship	2877 130th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-27	Matt Griswold	midwestsystems@live.com	Aurora	IA	United States	Creatleigh Griswold	Carslyn Griswold	Signed	(1) The employer does not elect the employers’ liability coverage.	Matt Griswold	midwestsystems@live.com	Owner	Aurora	IA	United States	Creatleigh Griswold	Carslyn Griswold	Signed
2155	2024-04-16 08:13	Anonymous (not verified)	94.188.207.225	Andrew M Riggins	Proprietorship	12905 N 1050th Road, Macomb, IL 61455	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-02	Andrew M Riggins	kellylanz1967@gmail.com	Macomb	IL	United States	Barb Coker	Scott Caspall	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew M Riggins	kellylanz1967@gmail.com	Self	Macomb	IL	United States	Barb Coker	Scott Caspall	Signed
1785	2023-08-06 17:37	Anonymous (not verified)	94.188.207.225	J and B Zuck Trucking LLC	Limited Liability Company	7310 E Airline Hwy Dunkerton, IA 50626	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-08	Justin Zuck	jandbzucktrucking@gmail.com	DUNKERTON	Iowa	United States	Justin Zuck	Rebekah Zuck	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Zuck	jandbzucktrucking@gmail.com	owner	DUNKERTON	Iowa	United States	Justin Zuck	Rebekah Zuck	Signed
2191	2024-04-29 10:09	Anonymous (not verified)	94.188.207.225	Anthony Rakestraw	Proprietorship	1262 S Kellogg St., Galesburg, IL 61401	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-29	Anthony Rakestraw	gazzork2@yahoo.com	Galesburg	Know	Illinois	Cheryl Ross	Larry Rheinschmidt	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony Rakestraw	gazzork2@yahoo.com	owner	Galesburg	Knox	Illinois	Cheryl Ross	Larry Rheinschmidt	Signed
1850	2023-09-20 16:28	Anonymous (not verified)	94.188.207.225	JB DOCK SERVICE	Limited Liability Company	1313 34TH ST 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.	2023-09-20	JONATHON BRUNSVOLD	jbdockservice@gmail.com	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	JONATHON BRUNSVOLD	jbdockservice@gmail.com	SELF	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1650	2023-05-16 12:06	Anonymous (not verified)	94.188.207.225	R & J Transport	Proprietorship	85152 US HWY 81 PIERCE NE 68767	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-16	Ray Tom Clausen III	jamieleabeutler2013@gmail.com	Pierce	NE	United States	Jamie Clausen	Ann Siebrandt	Signed	(1) The employer does not elect the employers’ liability coverage.	Ray T Clausen III	jamieleabeutler2013@gmail.com	Owner	Pierce	Pierce	Ne	Jamie Clausen	Ann Siebrandt	Signed
2209	2024-05-07 15:03	Anonymous (not verified)	94.188.207.225	THE FURNITURE GIRL LLC	Limited Liability Company	19257 CONIFER LN COUNCIL BLUFFS, IA 51503	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-07	PATTI WIGGINS	pwiggins@npdodge.com	VILLISCA	MONTGOMERY	IA	NATHAN HULL	JESSICA GARDNER	Signed	(1) The employer does not elect the employers’ liability coverage.	PATTI WIGGINS	pwiggins@npdodge.com	SELF	VILLISCA	MONTGOMERY	IA	NATHAN HULL	JESSICA GARDNER	Signed
1630	2023-05-09 08:54	Anonymous (not verified)	94.188.207.225	Ronald McChane	Proprietorship	400 Lewellen dr nw, CEDAR RAPIDS, IA 52405, 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.	2023-05-09	Ronald McChane	rws79213@gmail.com	Cedar Rapids	Linn	Iowa	Jordan Nisiewicz	Charles Woods	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Iowa	Charles Woods	Jordan Loyd	Signed
2094	2024-03-14 10:16	Anonymous (not verified)	94.188.207.225	Timothy Deutmeyer	Proprietorship	4014 iowa rd Center Point IA 52213	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-14	Timothy Francis Deutmeyer	timothydeutmeyer65@gmail.com	Center Point	Linn	Iowa	JAKE. Mcnurlaen	Kevin Kinzebach	Signed	(1) The employer does not elect the employers’ liability coverage.	Timothy Francis Deutmeyer	timothydeutmeyer65@gmail.com	Owner	CENTER POINT	Linn	Iowa	Jake Mcnurlaen	Kevin Kinzebach	Signed
1929	2023-11-30 10:46	Anonymous (not verified)	94.188.207.225	White Masonry, Inc.	Proprietorship	15141 Bluff Trl., Carlisle, IA 50047	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-30	Jeff White	whitemasonry1979@hotmail.com	Carlisle	IA	IA	Cathleen Marie White	Sam Jeffrey White	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeffrey Dean White	WHITEMASONRY1979@HOTMAIL.COM	Self	CARLISLE	ia	ia	Cathleen Marie White	Sam Jeffrey White	Signed
1931	2023-12-01 18:01	Anonymous (not verified)	94.188.207.225	Jay Wang	Limited Liability Company	16672 Verona Hills Dr, Clive IA 50325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-01	Jay Wang	jaywang@wasabidsm.com	Clive	US	IA	WenHui chen	Yingna Zheng	Signed	(1) The employer does not elect the employers’ liability coverage.	Jay Wang	Jaywang@wasabidsm.com	Self	Clive	US	IA	WenHui Chen	Yingna Zheng	Signed
1604	2023-04-26 09:03	Anonymous (not verified)	94.188.207.225	LeafHome Solutions LLC	Limited Liability Company	3060 SE Grimes Boulevard Grimes, IA 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-26	Braedyn Baylor	bbaylor66@gmail.com	West des moines	Polk	Iowa	Cassidy Tolle	Jeffrey Baylor	Signed	(1) The employer does not elect the employers’ liability coverage.	Braedyn Baylor	bbaylor66@gmail.com	Self	West Des Moines	Polk	Iowa	Julie Baylor	Brianna Stephens	Signed
1752	2023-07-17 13:21	Anonymous (not verified)	94.188.207.225	GPS Construction	Limited Liability Company	920 Wolf Creek Polk City, IA 50226	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2023-07-17	Gregory Schultz	gregpschultz@gmail.com	POLK CITY	IA	United States	Dillon Temple	Derek Temple	Signed	(1) The employer does not elect the employers’ liability coverage.	Gregory Schultz	gregpschultz@gmail.com	Owner	POLK CITY	IA	United States	Dillon Temple	Derek Temple	Signed
1669	2023-05-30 11:05	Anonymous (not verified)	94.188.207.225	Projects Under Development LLC	Limited Liability Company	2516 Hickory Grove Rd Davenport IA 52804	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-30	James Stock	jamese1053@gmail.com	Davenport	Scott	Ia	Ronald Lang	Karen Walker	Signed	(1) The employer does not elect the employers’ liability coverage.	James Stock	jamese1053@gmail.com	Owner	Davenport	Scott l	Ia	Ronald Lang	Karen Walker	Signed
2075	2024-03-05 22:32	Anonymous (not verified)	94.188.207.225	Steve Roland Trucking LLC	Limited Liability Company	2141 Wadsley Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-05	Steve Roland	roland.farms@yahoo.com	Sac City	IA	United States	Caylee Hoffard	Kristen Wirtjers	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Roland	roland.farms@yahoo.com	Owner/Member	Sac City	IA	United States	Caylee Hoffard	Kristen Wirtjers	Signed
1697	2023-06-20 14:36	Anonymous (not verified)	94.188.207.225	Quick Logistics LLC	Limited Liability Company	3817 Orleans Avenue, Sioux City, IA 51106	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Tony J Moeller	quick_logistics@outlook.com	Sioux City	IA	United States	Jordan Sitzmann	Cody Stultz	Signed	(1) The employer does not elect the employers’ liability coverage.	Tony J Moeller	quick_logistics@outlook.com	Owner	Sioux City	IA	United States	Jordan Sitzmann	Cody Stultz	Signed
1759	2023-07-26 07:09	Anonymous (not verified)	94.188.207.225	Lima Charlie LLC	Limited Liability Company	56066 257th Street, Glenwood, IA 51534	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-26	Larry Joshua Homan	Joshua@Lima-Charlie.biz	Flatonia	TX	United States	Leisha Kolb	Troy Kolb	Signed	(1) The employer does not elect the employers’ liability coverage.	Larry Joshua Homan	Joshua@lima-charlie.biz	Owner	Flatonia	Texas	United States	Leisha Kolb	Troy Kolb	Signed
1730	2023-07-09 23:39	Anonymous (not verified)	94.188.207.225	Steffens Constuction	Proprietorship	68222 Lansing Road, Wiota, IA 50274	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-07	Bradyn Richard Steffens	steffens4211@gmail.com	Wiota	Cass	Iowa	Katrina Sonntag	Chris Obrien	Signed	(1) The employer does not elect the employers’ liability coverage.	Audra Kelley Steffens	steffens4211@gmail.com	wife	Wiota	Cass	Iowa	Katrina Sonntag	Chris Obrien	Signed
1543	2023-03-29 15:37	Anonymous (not verified)	94.188.207.225	Sulzner Construction LLC	Limited Liability Company	210 N CHERRY ST, PO BOX 264	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-29	Aksel C Sulzner	akselsmoke@gmail.com	Mechanicsville	IA	United States	Toni Pollard	Phil Rouse	Signed	(1) The employer does not elect the employers’ liability coverage.	Aksel C Sulzner	akselsmoke@gmail.com	Self	Mechanicsville	IA	United States	Toni Pollard	Phil Rouse	Signed
1516	2023-03-14 09:00	Anonymous (not verified)	94.188.207.225	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln ST., Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-14	Bart Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed	(1) The employer does not elect the employers’ liability coverage.	Bart Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed
1645	2023-05-12 14:48	Anonymous (not verified)	94.188.207.225	VL Drywall LLC	Limited Liability Company	1608 6th Ave SE Cedar Rapids	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-12	LESLIE LEYVA	lleyva9696@gmail.com	Cedar Rapids	LINN	Iowa	Brad Bower	Chris Hay	Signed	(1) The employer does not elect the employers’ liability coverage.	Leslie Leyva	lleyva9696@gmail.com	Self	Cedar Rapids	Linn	Iowa	Chris Hay	Brad Bower	Signed
1841	2023-09-14 13:52	Anonymous (not verified)	94.188.207.225	Double M Construction LLC	Limited Liability Company	3886 Diamond Rd, Elgin, IA 52141	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-16	Eli Miller	elimiller@gmail.com	Iowa	Fayette	Iowa	Julie Schick	Kelly Matt	Signed	(1) The employer does not elect the employers’ liability coverage.	Eli Miller	elimiller@gmail.com	self	Elgin	Fayette	Iowa	Julie Schick	Kelly Matt	Signed
2165	2024-04-19 14:05	Anonymous (not verified)	94.188.207.225	Apex Striping LLC	Limited Liability Company	1325 Western Ave, cedar Falls, IA. 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-19	Chaz Ernest Torres	admin@apexstripingia.com	Cedar Falls	Blackhawk	Iowa	Theresa Jo Torres	Eloy James Torres	Signed	(1) The employer does not elect the employers’ liability coverage.	Chaz Ernest Torres	admin@apexstripingia.com	Self	Cedar Falls	Blackhawk	Iowa	Theresa Jo Torres	Eloy James Torres	Signed
2001	2024-01-26 10:41	Anonymous (not verified)	94.188.207.225	4 Sons Splicing & Activation	Proprietorship	13510 W Brazos Bend Dr, Needville, TX 77461-9525	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-26	John Kevin Steil	foursons1990@steil.org	Needville	Ft. Bend	Texas	Dennis Reeves Oliver	Stephanie Ranae Oliver	Signed	(1) The employer does not elect the employers’ liability coverage.	Helen Frances Steil	foursons1990@steil.org	Spouse	Needville	Ft. Bend	Texas	Dennis Reeves Oliver	Stephanie Ranae Oliver	Signed
1825	2023-08-30 11:16	Anonymous (not verified)	94.188.207.225	Quad City Glass	Proprietorship	1330 N Harrison St. Davenport, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-30	Jacob Brown	quadcityglass@gmail.com	Davenport	Scott	IOWA	na	na	Signed	(1) The employer does not elect the employers’ liability coverage.	Quad City Glass	Quadcityglass@gmail.com	employee	Davenport	Scott	IOWA	na	na	Signed
1896	2023-11-03 14:23	Anonymous (not verified)	94.188.207.225	Shane Adams	Limited Liability Company	3944 54th st Des Moines,IA 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-03	Shane Steven Adams	Shane6079@gmail.com	Des Moines	Polk	Iowa	Justin Mace	Denice Sutton	Signed	(1) The employer does not elect the employers’ liability coverage.	Shane Adams	Shane6079@gmail.com	Owner	Des Moines	Polk	Iowa	Justin Mace	Denice Sutton	Signed
1593	2023-04-24 09:41	Anonymous (not verified)	94.188.207.225	Tyler Wilson	Proprietorship	5319 Ruhd Street Southwest, Cedar Rapids, IA 52404, United States	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-24	Tyler Wilson	t.wilson237@gmail.com	Cedar Rapids	Linn	Missouri	Jordan Loyd	Jordan Nisiewicz	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Jordan Loyd	Robert Snyder	Signed
2124	2024-03-28 13:47	Anonymous (not verified)	94.188.207.225	Gudiel Construction & Masonry LLC	Limited Liability Company	303 Lacona 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.	2024-03-28	Santiago Gudiel Lopez	gudielsantiago972@gmail.com	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Santiago Gudiel Lpez	gudielsantiago972@gmail.com	Self	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed
2189	2024-04-29 09:23	Anonymous (not verified)	94.188.207.225	Sals Home Improvements LLC	Limited Liability Company	3750 NW Maple Ct Ankeny IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-29	Salvador Gomez	salvadorg27@hotmail.com	Ankeny	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Salvador Gomez	salvadorg27@hotmail.com	Self	Ankeny	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed
1743	2023-07-13 10:24	Anonymous (not verified)	94.188.207.225	Sindi Merida Alvarez MA Consttuction LLC	Proprietorship	2048 Lyon St DM, IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-24	Sindi Merida-Alvarez dba MA Construction LLC	deb@piciowa.com	Des Moines	Polk	IA	Debra Stratton`	kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Sindi Merida Alvarez dba MA Construction LLC	deb@piciowa.com	self	Des Moines	Polk	Iowa	Debra Stratton	Kelly Denger	Signed
2016	2024-02-01 09:20	Anonymous (not verified)	94.188.207.225	Imperium Outdoor Solutions	Proprietorship	114 W Clanton St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-01	Austin Beener	abeener033@gmail.com	St Charles	IA	United States	Austin Beener	Austin Beener	Signed	(1) The employer does not elect the employers’ liability coverage.	Austin Beener	abeener033@gmail.com	Operator	St Charles	IA	United States	Austin Beener	Austin Beener	Signed
1891	2023-11-02 06:24	Anonymous (not verified)	94.188.207.225	DOC Services	Proprietorship	3313 , E 7th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-01	Quentin Ferguson	1quensy@gmail.com	Des Moines	Polk	IA	Dione Fergsuon	Quensy Ferguson	Signed	(1) The employer does not elect the employers’ liability coverage.	Quentin Ferguson	1quensy@gmail.com	Self	Des Moines	Polk	Ia	Dione Ferguson	Quensy Ferguson	Signed
1818	2023-08-25 15:16	Anonymous (not verified)	94.188.207.224	Global Roofing LLC	Limited Liability Company	504 Heritage Rd Cedar Falls IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-20	Yenifer Yomara Hernandez Solis	Grjrd808504@outlook.com	Cedar Falls	Black Hawk	Iowa	Noemi Guerrero	Andres B Montoya	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Rafael Delgado Marin	Grjrd808504@outlook.com	member	Cedar Falls	Black Hawk	Iowa	Noemi Guerrero	Andres B Montoya	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
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
1747	2023-07-14 12:18	Anonymous (not verified)	94.188.207.224	WIL-EQUIPMENT	Limited Liability Company	16400 Highway 92 Indianola Iowa 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.	2023-07-14	Brian Wilson	wileq@outlook.com	Indianola	Warren	Iowa	Linda Jill Wilson	Megan Elizabeth Wilson	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Brian Wilson	wileq@outlook.com	Owner of Business	Indianola	Iowa	United States	Linda Jill Wilson	Megan Elizabeth Wilson	Signed
1803	2023-08-15 19:03	Anonymous (not verified)	94.188.207.224	Teimer Trucking LLC	Limited Liability Company	3277 102nd St. Durant, IA 52747-9524	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-15	Daniel Dennis Treimer	dtreimer65@gmail.com	Tipton	Iowa	United States	Spencer Lea Parsons	Sydney Rae Lane	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Dennis Treimer	dtreimer65@gmail.com	Self	Tipton	Iowa	United States	Spencer Lea Parsons	Sydney Rae Lane	Signed
1711	2023-06-26 16:50	Anonymous (not verified)	94.188.207.224	Innovative Behavioral Therapy, LLC	Limited Liability Company	915 Main St. Adel IA 50003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-26	Ashley Andrew	ashley@innovativebehavioraltherapy.com	Adel	Dallas	Iowa	Thomas Atherton	Brenda Barto	Signed	(1) The employer does not elect the employers’ liability coverage.	Ashley Andrew	ashley@innovativebehavioraltherapy.com	Self	Adel	Dallas	Iowa	Thomas Atherton	Brenda Barto	Signed
1838	2023-09-12 10:48	Anonymous (not verified)	94.188.207.224	OKOBOJI TSHIRT CENTER LLC	Limited Liability Company	PO BOX 158 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.	2023-09-12	ADIR SEBAN	PACIFIC513@YAHOO.COM	ARNOLDS PARK	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	ADIR SEBAN	PACIFIC513@YAHOO.COM	SELF	ARNOLDS PARK	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1720	2023-07-05 07:19	Anonymous (not verified)	94.188.207.224	Doug FGerneding	Proprietorship	21618 270th St Carroll IA 51401	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-05	Doug Ferneding	dougferneding@gmail.com	Carroll	Iowa	Iowa	Jaynie Ferneding	Brenda Klein	Signed	(1) The employer does not elect the employers’ liability coverage.	Doug Ferneding	dougferneding@gmail.com	same	Carroll	Iowa	Iowa	Jaynie Ferneding	Brenda Klein	Signed
1657	2023-05-22 14:31	Anonymous (not verified)	94.188.207.224	Collum Plumbing, LLC	Limited Liability Company	610 West 20th, Cedar Falls, IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-22	Stephen Collum	collumplumbing@cfu.net	Cedar Falls	Iowa	United States	Mike Thode	Linda Thode	Signed	(1) The employer does not elect the employers’ liability coverage.	Stephen Collum	collumplumbing@cfu.net	Owner/Member of LLC	Cedar Falls	Black Hawk	Iowa	Mike Thode	Linda Thode	Signed
1980	2024-01-10 11:32	Anonymous (not verified)	94.188.207.224	Raudel Correa	Proprietorship	1924 23rd St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-02	Raudel Correa	deb@piciowa.com	Des Moines	Polk	Iowa	Martin Pinon	Debra Stratton	Signed	(1) The employer does not elect the employers’ liability coverage.	Raudel Correa	deb@piciowa.com	self	Des Moines	Polk	Iowa	Martin Pinon	Debra Stratton	Signed
1558	2023-04-06 19:15	Anonymous (not verified)	94.188.207.224	Bechler Services	Limited Liability Partnership	5244 180th Street Sibley 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.	2023-04-06	Payton Bechler	bechler.services@gmail.com	Sibley	Osceola	Iowa	Kody Koerselman	Richard Bechler	Signed	(1) The employer does not elect the employers’ liability coverage.	Payton Bechler	bechler.services@gmail.com	Owner	Sibley	Osceola	Iowa	Kody Koerselman	Richard Bechler	Signed
1822	2023-08-29 11:52	Anonymous (not verified)	94.188.207.224	Ellison building and repair	Limited Liability Company	2722 645th ave moravia iowa 52571	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-18	Keeton Ellison	keeton2005@gmail.com	Moravia	Appanoose	Iowa	Cory Ellison	Sammy Ellison	Signed	(1) The employer does not elect the employers’ liability coverage.	Sammy Ellison	sammyllsn@yahoo.com	Mom	Moravia	Monroe	Iowa	Cory Ellison	Sammy Ellison	Signed
1672	2023-06-01 15:16	Anonymous (not verified)	94.188.207.224	Raudel Correa Correa	Proprietorship	1924 23rd St Des Moines, IOwa 50313	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-01	Raudel Correa Correa	correaraudel6@gmail.com	Des Moines	Polk	Iowa	Debra Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Raudel Correa Correa	correaraudel6@gmail.com	self	DM	Polk	IA	Den Stratton	Kelly Denger	Signed
1948	2023-12-11 10:36	Anonymous (not verified)	94.188.207.224	Just Like New Details LLC	Limited Liability Company	4665 NE 7th 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.	2023-12-11	Trinity Schroeder	trinity@justlikenewdetails.com	Des Moines	Polk	Iowa	Jayson Jones	Nikki Wilks	Signed	(1) The employer does not elect the employers’ liability coverage.	Trinity Schroeder	trinity@justlikenewdetails.com	Member	Des Moines	Polk	Iowa	Jayson Jones	Nikki Wilks	Signed
2031	2024-02-07 10:54	Anonymous (not verified)	94.188.207.224	PETER MARTENS	Proprietorship	305 4TH STREET NORTH, ALBERT CITY, IOWA 50510	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-07	PETER KLASSEN MARTENS	pkmmartens@hotmail.com	ALBERT CITY	BUENA VISTA	IOWA	ROBERT EUGENE BELT	JOHN CLARENCE OLERICH	Signed	(1) The employer does not elect the employers’ liability coverage.	PETER KLASSEN MARTENS	pkmmartens@hotmail.com	SELF	ALBERT CITY	SAC	IOWA	ROBERT EUGENE BELT	JOHN CLARENCE OLERICH	Signed
1855	2023-09-27 12:56	Anonymous (not verified)	94.188.207.224	Lincoln Hotel Group	Limited Liability Company	9240 Andermatt Drive Suite 1	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-27	John Edward Klimpel	jklimpel@lincolnhotelgroup.com	Lincoln	Lancaster	NE	Carrie A. Fleck	Jill N. Korta	Signed	(1) The employer does not elect the employers’ liability coverage.	Brent Besch	brent.besch@marshmma.com	Client	Lincoln	Nebraska	NE	Carrie A Fleck	Jill N Korta	Signed
1487	2023-02-27 22:12	Anonymous (not verified)	94.188.207.224	Panda garden	Proprietorship	105 2nd Ave se cresco ia 52136	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-10	Jing Chen	jingchen9968@gmail.com	Cresco	Howard	Iowa	Leyang Zhou	Guy Chen	Signed	(1) The employer does not elect the employers’ liability coverage.	Jing Chen	jingchen9968@gmail.com	Self	Cresco	Howard	Iowa	Leyang zhou	Guy Chen	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
1695	2023-06-19 06:54	Anonymous (not verified)	94.188.207.224	Leaf Filter	Proprietorship	3060 SE Grimes Blvd Unit 100 Grimes, IA 50111 United States	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-17	Trenton Finch	tjfinch10@gmail.com	Kellogg	Jasper	Iowa	Teagan Kruse	Diane Finch	Signed	(1) The employer does not elect the employers’ liability coverage.	Trenton Finch	tjfinch10@gmail.com	Subcontractor	Kellogg	Jasper	Iowa	Teagan Kruse	Diane Finch	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
1879	2023-10-26 13:17	Anonymous (not verified)	94.188.207.224	CR Exteriors	Proprietorship	1636 Parktown Ct NE Unit 9	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-26	corey becker	cab222.ab@gmail.com	cedar rapids	linn	iowa	Brian Ashlock	Brian Coover	Signed	(1) The employer does not elect the employers’ liability coverage.	Corey Becker	cab222.ab@gmail.com	same	Cedar Rapids	Linn	Iowa	Brian Ashlock	Brian Coover	Signed
2058	2024-02-26 16:32	Anonymous (not verified)	94.188.207.224	performance gutter	Proprietorship	PO BOX 306, NORWALK IOWA 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.	2024-02-26	RICHARD BAINTER	RWBNJ50@AOL.COM	NORWALK	WARREN	IOWA	DYLAN LANE	JAMES LANE	Signed	(1) The employer does not elect the employers’ liability coverage.	RICHARD BAINTER	RWBNJ50@AOL.COM	OWNER	NORWALK	WARREN	IOWA	DYLAN LANE	JAMES LANE	Signed
1597	2023-04-24 16:03	Anonymous (not verified)	94.188.207.224	4 Iowa Construction LLC	Limited Liability Company	1750 Lyon St Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-24	Luis E Cancino Mireles	luiscancino55@gmail.com	Des Moines	Polk	Iowa	Jon Buller	Terry Miles	Signed	(1) The employer does not elect the employers’ liability coverage.	Luis E Cancino Mireles	luiscancino55@gmail.com	self / 100% owner / manager of the LLC	Des Moines	Polk	Iowa	Jon Buller	Terry Miles	Signed
2148	2024-04-15 11:15	Anonymous (not verified)	94.188.207.224	Derek Fetzer	Proprietorship	360 250th St, West Branch, IA 52358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-17	Dere W Fetzer	kellylanz1967@gmail.com	West Branch	IA	United States	Maribelle Lund	Carl Lund	Signed	(1) The employer does not elect the employers’ liability coverage.	Derek Fetzer	kellylanz1967@gmail.com	Self	West Branch	IA	United States	Maribelle Lund	Carl Lund	Signed
2050	2024-02-16 09:45	Anonymous (not verified)	94.188.207.224	Mario Construction	Limited Liability Company	1755 Huntington Rd Waterloo IA 50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-16	Mario Lainez	brocalainez73@gmail.com	Waterloo	Black Hawk	Iowa	Karolina Saenz	Alejandra Maradiaga	Signed	(1) The employer does not elect the employers’ liability coverage.	Mario Lainez	brocalainez73@gmail.com	Self	Waterloo	Black Hawk	Iowa	Karolina Saenz	Alejandra Maradiaga	Signed
1934	2023-12-01 22:43	Anonymous (not verified)	94.188.207.224	wasabi johnston llc	Limited Liability Company	7115 ridgedale ct, johnston, IA, 50131	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-01	wenhui chen	michaelchen@wasabidsm.com	johnston	polk	Iowa	wen Zheng	Jenna Yu	Signed	(1) The employer does not elect the employers’ liability coverage.	wenhui chen	michaelchen@wasabidsm.com	owner	johnston	polk	IOWA	wen zheng	Jenna Yu	Signed
1996	2024-01-24 10:30	Anonymous (not verified)	94.188.207.224	E&p quality home remodeling llc	Limited Liability Company	2660 NE 44th ct desmoines 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.	2024-01-24	Pedro martinez	pmsalas82@gmail.com	Des Moines	Polk	Iowa	Rogelio martinez	Rigoberto martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Pedro Martinez	pmsalas82@gmail.com	Owner	Des Moines	Polk	Iowa	Rogelio Martínez	Rigoberto Martínez	Signed
1776	2023-08-03 13:51	Anonymous (not verified)	94.188.207.224	Lucas Adam Peterson	Proprietorship	2833 SE 68th St Pleasant Hill, IA 50327	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-03	Lucas Adam Peterson	Luke.Peterson.mzub@gmail.com	Pleasant Hill	POLK	IOWA	Sarah Peterson	Samuel Peterson	Signed	(1) The employer does not elect the employers’ liability coverage.	Lucas Adam Peterson	Luke.Peterson.mzub@gmail.com	Self	PLEASANT HILL	IA	United States	Sarah Peterson	Samuel Peterson	Signed
1763	2023-07-26 12:46	Anonymous (not verified)	94.188.207.224	Down Home Decor Inc	Proprietorship	1021 2nd Ave SE Ste 200 - Dyersville, IA 52040	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-26	Steve Knipper	jheims@english-insurance.com	Dyersville	Dubuque	IA	Joyce Heims	Derrick Parsons	Signed	(1) The employer does not elect the employers’ liability coverage.	Joyce Heims	jheims@english-insurance.com	self agent	Dyersville	IA	IA	Joyce Heims	Derrick Parsons	Signed
1964	2023-12-22 10:19	Anonymous (not verified)	94.188.207.224	Dale Pahl	Proprietorship	711 N. 1St. B105 Eldridge IA 52748	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-21	Dale Pahl	Pada7910@gmail.com	Eldridge	Scott	Iowa	Samantha weston	Rick mayerhofer	Signed	(1) The employer does not elect the employers’ liability coverage.	Dale	Pada7910@gmail.com	Self	Eldridge	Scott	IA	Samantha weston	Rick Mayerhofer	Signed
1754	2023-07-19 08:52	Anonymous (not verified)	94.188.207.224	Dustin Scoggins	Limited Liability Company	1723 19th ave rock island Illinois	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-19	Dustin Shane Scoggins	dscoggins625@gmail.com	Rock island	Rock island county	Illinois	Emily Smith-Scoggins	Emily Smith-Scoggins	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin Shane Scoggins	dscoggins625@gmail.com	Self	Rock island	Rock island county	Illinois	Emily Smith-Scoggins	Emily Smith-Scoggins	Signed
1779	2023-08-03 15:40	Anonymous (not verified)	94.188.207.224	Action Garage Builders	Limited Liability Company	1635 Kerry Lane, Jesup, IA 50648	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-03	Brady Huls	brady.cve@gmail.com	Cedar Falls	Black Hawk	Iowa	Tyler Reynolds	Joshua Carder	Signed	(1) The employer does not elect the employers’ liability coverage.	Troy Even	actiongaragebuilders@gmail.com	Owner	Jesup	Buchanan	Iowa	Tyler Reynolds	Joshua Carder	Signed
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
1846	2023-09-15 13:25	Anonymous (not verified)	94.188.207.224	Kg Roofing	Limited Liability Company	1820 1 Ave S, Fort Dodge IA 50501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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.	2023-09-15	Tyler Price	tylerprice636@gmail.com	Fort Dodge	Webster	IOWA	Ashley Bates	Breann Moore	Signed	(1) The employer does not elect the employers’ liability coverage.	Tyler	tylerprice636@gmail.com	Self	Fort Dodge	Webster	IOWA	Ashley Bates	Breann Moore	Signed
2217	2024-05-09 14:28	Anonymous (not verified)	94.188.207.224	Emmanual A Sanchez Chavez	Proprietorship	7301 Fleur Dr, Lot 10, Des Moines, IA 50325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-09	Emmanuel A Sanchez Chaves	alexsanchw3@gmail.com	Des Moines	Polk	Iowa	Jesus Garcia	Fabion Dalgato	Signed	(1) The employer does not elect the employers’ liability coverage.	Emmanuel A Sanchez Chavez	alexsanchw3@gmail.com	Person	Des Moines	Polk	Iowa	Jesus Garcia	Fabion Dalgato	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
1925	2023-11-28 09:44	Anonymous (not verified)	94.188.207.224	Pietro Solutions	Limited Liability Company	719 11th 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.	2023-11-28	Ronaldo Di Pietro	girodp@gmail.com	Rock Island	Rock Island	IL	Rita de Cássia Gallo	Antonio Carlos Gallo	Signed	(1) The employer does not elect the employers’ liability coverage.	Ronaldo Di Pietro	girodp@gmail.com	Self	Rock Island	Rock Island	IL	Rita de Cássia Gallo	Antonio Carlos Gallo	Signed
1491	2023-03-03 11:24	Anonymous (not verified)	94.188.207.224	Ray gist	Proprietorship	4330 nw 9th st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-03	Raymond Rex Gist	rrgist8@yahoo.com	Dsm	Polk	Ia	Amber Gist	Victor Brawdy	Signed	(1) The employer does not elect the employers’ liability coverage.	Raymond Rex Gist	rrgist8@yahoo.com	Same person	Dsm	Polk	Ia	Amber Gist	Victor Brawdy	Signed
2170	2024-04-22 10:11	Anonymous (not verified)	94.188.207.224	Joy Ride Transport	Limited Liability Company	3105 SE Miehe Drive, Grimes, IA 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-22	Ted Cochran	ted@ridejoyride.com	Clive	Dallas	IA	Lindsey Pace	Carissa Gehrking	Signed	(1) The employer does not elect the employers’ liability coverage.	Ted Cochran	ted@ridejoyride.com	Self	Clive	Dallas	IA	Lindsey Pace	Carissa Gehrking	Signed
1732	2023-07-10 13:22	Anonymous (not verified)	94.188.207.224	Jovan Guerrero	Proprietorship	2887 Jaden Lane Norwalk, Iowa 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.	2023-07-10	Jovan Guerrero	deb@piciowa.com	Norwalk	Warren	Iowa	Debra Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Jovan Guerrero	deb@piciowa.com	self	Norwalk	Warren	Iowa	Debra Stratton	Kelly Denger	Signed
2198	2024-05-02 11:26	Anonymous (not verified)	94.188.207.224	Sierra Stone LLC	Limited Liability Company	2504 E 37th 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.	2024-05-02	Daniel Nunez	danieln2024@gmail.com	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Nunez	danieln2024@gmail.com	Self	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed
1646	2023-05-15 13:13	Anonymous (not verified)	94.188.207.224	Aspen leaf Painting	Limited Liability Company	3846 Lower Beaver Rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-15	Michael Patrick Vajda	m.p.vajda@gmail.com	Des Moines	Polk	IA	Patrick Vajda	Mike Vajda	Signed	(1) The employer does not elect the employers’ liability coverage.	Mike Vajda	m.p.vajda@gmail.com	Self	Des Moines	Polk	IA	Mike Vajda	Michael Vajda	Signed
1685	2023-06-12 07:21	Anonymous (not verified)	94.188.207.224	Steven Boshart	Proprietorship	2172 Scales Bend Road Northeast, North Liberty, IA 52317, United States	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-12	Steven Boshart	sboshart1982@gmail.com	North Liberty, MO	Johnson	Iowa	Jordan Nisiewicz	Charles Wood	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Charles Wood	Jordan Loyd	Signed
2055	2024-02-23 14:54	Anonymous (not verified)	94.188.207.224	Neil Vonnahme	Proprietorship	13628 220th St., Arcadia, Iowa, 51430	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-20	Neil Vonnahme	neilvonnahme@gmail.com	Arcadia	Carroll	Iowa	Kyle Klein	Brenda Klein	Signed	(1) The employer does not elect the employers’ liability coverage.	Neil Vonnahme	neilvonnahme@gmail.com	Self	Arcadia	Carroll	Iowa	Kyle Klein	Brenda Klein	Signed
2006	2024-01-29 11:04	Anonymous (not verified)	94.188.207.224	Kevin Jones	Proprietorship	1500 15Th St. Milford IA 51351	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-29	KEVIN JONES	KEVINMJONES81@GMAIL.COM	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JOSEPH LORING	Signed	(1) The employer does not elect the employers’ liability coverage.	KEVIN JONES	KEVINMJONES81@GMAIL.COM	SELF	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JOSEPH LORING	Signed
1764	2023-07-27 09:56	Anonymous (not verified)	94.188.207.224	Tracy Spray	Proprietorship	479 old lincoln hwy Mechanicsville 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.	2023-07-27	Tracy spray	tspray9@hotmail.com	Mechanicsville	Cedar	Iowa	Dillon Williams	Leighton Raplinger	Signed	(1) The employer does not elect the employers’ liability coverage.	Tracy Spray	tspray9@hotmail.com	Owner	Mechanicsville	Cedar	Iowa	Dillon Williams	Leighton Raplinger	Signed
2149	2024-04-15 11:20	Anonymous (not verified)	94.188.207.224	Grady Yeggy	Proprietorship	211 3rd St. Riverside, IA 52327	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-11	Grady S Yeggy	kellylanz1967@gmail.com	Riverside	IA	United States	Amanda Yeggy	Leah Evans	Signed	(1) The employer does not elect the employers’ liability coverage.	Grady S Yeggy	kellylanz1967@gmail.com	Self	Riverside	IA	United States	Amanda Yeggy	Leah Yeggy	Signed
2202	2024-05-06 11:36	Anonymous (not verified)	94.188.207.224	Neil Wedeking	Proprietorship	408 Maple St, Nemaha, IA 50567	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-06	Neil Douglas Wedeking	nandjwedeking@frontiernet.net	Nemaha	Sac	Iowa	Joseph McCollum	Heather Husman	Signed	(1) The employer does not elect the employers’ liability coverage.	Neil Wedeking	nandjwedeking@frontiernet.net	Self	Nemaha	Sac	Iowa	Joseph Paul McCollum	Heather Lee Husman	Signed
1976	2024-01-04 15:48	Anonymous (not verified)	94.188.207.224	Brawdy Services	Proprietorship	7029 Prairie 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.	2024-01-01	Victor Brawdy	heather.l.brawdy@gmail.com	Urbandale	Polk	IA	Summer Munoz	Jennifer Wolters	Signed	(1) The employer does not elect the employers’ liability coverage.	Victor Brawdy	vb69ia@gmail.com	Self	Urbandale	Polk	IA	Summer Munox	Jennifer Wolters	Signed
1904	2023-11-13 09:27	Anonymous (not verified)	94.188.207.224	Paul White	Proprietorship	4991 Old C Boscobel, WI 53805	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-10	Paul White	darrele@ciains.biz	Boscobel	Grant	Wisconsin	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Paul White	darrele@ciains.biz	self	Boscobel	Grant	Wisconsin	Chris Fye	Darrel Elsbernd	Signed
1738	2023-07-11 10:51	Anonymous (not verified)	94.188.207.224	Augustin Santos	Proprietorship	109 Loomis Ave Des Moines, Iowa 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-05	Augustin Santos	deb@piciowa.com	Des Moines	Polk	Iowa	Deb Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Augustin Santos	deb@piciowa.com	self	Des Moines	Polk	Iowa	Deb Stratton	Kelly Denger	Signed
1619	2023-04-28 11:20	Anonymous (not verified)	94.188.207.224	Hunter Flying Service, LLC	Limited Liability Company	PO Box 215 Hunter, AR 72074	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-28	Adam Towe	hunterflying@att.net	Hartselle	Morgan	Alabama	Ronnie Skinner	Karen Gifford	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Lynn Cary	hunterflying@att.net	Owner	Hunter	Woodruff	Arkansas	Ronnie Skinner	Karen Gifford	Signed
1810	2023-08-21 10:18	Anonymous (not verified)	94.188.207.224	Vicente McCain	Proprietorship	524 panama st Nashua	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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.	2023-08-20	Jose V Mccain	Vic_mccain@yahoo.com	Nashua	IA	United States	Rafael McCain	Jessica McCain	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jose V Mccain	Vic_mccain@yahoo.com	Brother	Nashua	IA	United States	Rafael McCain	Jessica McCain	Signed
1761	2023-07-26 08:40	Anonymous (not verified)	94.188.207.224	Gerk Trucking	Proprietorship	401 W college, Stacyville, IA 50476	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-26	Charles W. Gerk	cwgerk@gmail.com	Stacyville	Mitchell	iowa	Jeannie Lemke	Robin Tabbert	Signed	(1) The employer does not elect the employers’ liability coverage.	Charles W. Gerk	cwgerk@gmail.com	Same	Stacyville	Mitchell	Iowa	Jeannie Lemke	Robin Tabbert	Signed
1900	2023-11-09 23:24	Anonymous (not verified)	94.188.207.224	Daniel Blanco	Proprietorship	1403 2nd Ave S	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-09	Daniel Blanco	chindan77@yahoo.com	Fort Dodge	IA	United States	Vanessa Blanco	Jorge Blanco	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Blanco	chindan77@yahoo.com	Self	Fort Dodge	IA	United States	Elva Castañeda	Vanessa Blanco	Signed
2048	2024-02-16 07:42	Anonymous (not verified)	94.188.207.224	Alexandra Machedon LLC	Proprietorship	319 N Western Street Stuart, IA 50250	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-16	Alexandra Machedon	ali@alimachedon.com	Stuart	USA	Iowa	Jessica Cash	Vicki Collins	Signed	(1) The employer does not elect the employers’ liability coverage.	Alexandra Machedon	ali@alimachedon.com	Self	Stuart	US	IA	Jessi Cash	Vicki Collins	Signed
2074	2024-03-04 16:56	Anonymous (not verified)	94.188.207.224	IG painting Llc	Limited Liability Company	416 51st ST West des moines,IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-01	antonio J Iglesias	antonio_joserene@hotmail.com	west Des moines	polk	iowa	Raul Gomez	Bruno Cruz	Signed	(1) The employer does not elect the employers’ liability coverage.	Antonio J Iglesias	antonio_joserene@hotmail.com	not relationship	West des Moines	polk	iowa	Raul Gomez	Bruno cruz	Signed
2224	2024-05-15 11:22	Anonymous (not verified)	94.188.207.224	Community Centered Counseling Services, LLC	Limited Liability Company	2711 W 63rd St Ste 3 Davenport, IA 52806	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-26	Adam Vilmont	avilmont@cccs.me	Davenport	Scott	Iowa	Briane Franks	Amanda Tesch	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Vilmont	avilmont@cccs.me	Self	Davenport	Scott	Iowa	Briane Franks	Amanda Tesch	Signed
2212	2024-05-08 13:26	Anonymous (not verified)	94.188.207.224	Lifetime Roofing Installations, LLC	Limited Liability Company	703 2nd St. SW Tripoli, IA 50676	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-08	Kurtis Walvatne	lifetimeroofing12@yahoo.com	Tripoli	Bremer	Iowa	Mike Meyer	Kelly Walvatne	Signed	(1) The employer does not elect the employers’ liability coverage.	Kurtis Walvatne	lifetimeroofing12@yahoo.com	Owner	Tripoli	Bremer	Iowa	Mike Meyer	Kelly Walvatne	Signed
2194	2024-04-30 14:57	Anonymous (not verified)	94.188.207.223	Juan Raymundo Hernandez	Proprietorship	3317 Scott Ave 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.	2024-01-25	Juan Raymundo Hernandez	deb@piciowa.com	Des Moines	Poik	Iowa	Kelly Denger	Debra Stratton	Signed	(1) The employer does not elect the employers’ liability coverage.	Juan Raymundo Hernandez	deb@piciowa.com	self	Des Moines	Polk	Iowa	Kelly Denger	Debra Stratton	Signed
1863	2023-10-06 12:24	Anonymous (not verified)	94.188.207.223	ADRIAN CAZARES HERNANDEZ	Proprietorship	409 N 16TH PL, 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.	2023-10-06	ADRIAN CAZARES HERNANDEZ	JOEL@WALKERINSURANCE.COM	ESTHERVILLE	EMMET	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	ADRIAN CAZARES HERNANDEZ	JOEL@WALKERINSURANCEIA.COM	SELF	ESTHERVILLE	EMMET	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
2125	2024-03-28 23:17	Anonymous (not verified)	94.188.207.223	MB Lawn Care	Limited Liability Company	7018 Deerview Dr Urbandale IA 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-28	Mirnes Becirovic	Mirnes2012@me.com	Urbandale	Polk	Iowa	Mirnes Becirovic	Mirnes Becirovic	Signed	(1) The employer does not elect the employers’ liability coverage.	Mirnes Becirovic	mirnes2012@me.com	Owner	Urbandale	Polk	Iowa	Mirnes Becirovic	Mirnes Becirovic	Signed
1768	2023-07-29 11:10	Anonymous (not verified)	94.188.207.223	Makana Industries LLC	Limited Liability Company	1800 Grand Ave #352, West Des Moines, IA 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-29	Matthew Akana	mandiremod515@gmail.com	West Des Moines	Polk	Iowa	Catherine Sobrado	James Fowler	Signed	(1) The employer does not elect the employers’ liability coverage.	Rocket Lawyer Corporate Services LLC	mandiremod515@gmail.com	Registered agent	Des Moines	Polk	Iowa	Catherine Sobrado	James Fowler	Signed
2015	2024-02-01 08:26	Anonymous (not verified)	94.188.207.223	Salazar Builders inc	Proprietorship	29175 365th st van meter ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-01	José Luis ángeles Salazar	salazarbuilders15@gmail.com	Van meter ia	Dallas	Iowa	Adam Paul Boge	Lance Owen Webster	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Luis angeles Salazar	salazarbuilders15@gmail.com	Sub contractor	Van meter	Dallas	Iowa	Adam Paul Boge	Lance Owen Webster	Signed
1831	2023-09-08 11:50	Anonymous (not verified)	94.188.207.223	GFORCE	Limited Liability Company	529 Anderson Street Jewell IA 50130	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-06	Colten Abram Griffin	G6@q.com	Ames	Story	Iowa	Scott Andrew Griffin	Hunter Austin Griffin	Signed	(1) The employer does not elect the employers’ liability coverage.	Hunter Austin Griffin	G6@q.com	Partner	Urbandale	Polk	Iowa	Scott Andrew Griffin	Colten Abram Griffin	Signed
2024	2024-02-06 20:31	Anonymous (not verified)	94.188.207.223	BTS Custom Floors	Proprietorship	22 wenwood cir	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-06	Brandon Clay	Brandon.btscustomfloors@gmail.com	Council Bluffs	Iowa	United States	Darin Thompson	Amber Swanson	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandon Clay	Brandon.btscustomfloors@gmail.com	I am them	Council Bluffs	Iowa	United States	Amber Swanson	Darin Thompson	Signed
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
2025	2024-02-06 20:49	Anonymous (not verified)	94.188.207.223	Blue Dog Stump Grinding	Limited Liability Company	32199 Sumac Road Neola IA 51559	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-06	Zebulan	bluedogstumpgrinding@gmail.com	Neola	Pottowattamie	Iowa	Kelsey Wahle	Mike Stamp	Signed	(1) The employer does not elect the employers’ liability coverage.	Zebulan Wahle	bluedogstumpgrinding@gmail.com	Owner	Neola	Pottowattomie	Iowa	Kelsey Wahle	Mike Stamp	Signed
1771	2023-08-01 09:59	Anonymous (not verified)	94.188.207.223	Modern Builder LLC	Limited Liability Company	30008 560th St Chariton IA 50049	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-01	Tatyana Sayenko	modernbuilder02@gmail.com	Chariton	Lucas	Iowa	Arthur Sayenko	Viktor Sayenko	Signed	(1) The employer does not elect the employers’ liability coverage.	Tatyana Sayenko	modernbuilder02@gmail.com	owner/ Family	Chariton	Lucas	Iowa	Arthur Sayenko	Viktor Sayenko	Signed
1798	2023-08-14 12:16	Anonymous (not verified)	94.188.207.223	David Robles	Proprietorship	3912 E 23rd St Des Moines, Iowa 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-09	David Robles	deb@piciowa.com	Des Moines	Polk	Iowa	Debra E Stratton	Kelly K Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	David Robles	deb@piciowa.com	self	Des Moines	Polk	Iowa	Kelly K Denger	Debra E Stratton	Signed
2086	2024-03-08 19:11	Anonymous (not verified)	94.188.207.223	Handyman & More	Limited Liability Company	1214 Lindwood 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.	2024-03-08	Dustin allen Bergman	dustinbergman86@gmail.com	Carter Lake	IA	United States	Reesa Edie	Douglas Scadin	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin allen Bergman	dustinbergman86@gmail.com	Owner of company	Carter Lake	IA	United States	Reesa Edie	Douglas Scadin	Signed
1547	2023-03-30 08:45	Anonymous (not verified)	94.188.207.223	Palomeque Gutter LLC	Limited Liability Company	2004 SE 24TH ST	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-30	Philips Palomeque	ecuaphilips94@gmail.com	Grimes	USA	IA	Philips Palomeque	Philips Palomeque	Signed	(1) The employer does not elect the employers’ liability coverage.	Philips Palomeque	ecuaphilips94@gmail.com	My self	Grimes	USA	Ia	Philips Palomeque	Philips Palomeque	Signed
1885	2023-10-29 08:05	Anonymous (not verified)	94.188.207.223	MB Radon Services	Limited Liability Company	13206 State Hwy 2, Lamoni, Iowa, 50140	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-29	Kyle Ramaeker	raymaker83@gmail.com	LAMONI	IA	United States	Adam Boge	Lance Webster	Signed	(1) The employer does not elect the employers’ liability coverage.	Kyle Ramaeker	raymaker83@gmail.com	Owner/Operator	LAMONI	IA	United States	Adam Boge	Lance Webster	Signed
1858	2023-10-03 13:29	Anonymous (not verified)	94.188.207.223	Quad city drywall Solutions LLC	Limited Liability Company	5804 n thornwood ave Davenport iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-03	Erivan Emmanuel Montalvo Delcompare	montalvobills6@gmail.com	Davenport	Scott	Iowa	Natalia Ann Montalvo	Juan Portela	Signed	(1) The employer does not elect the employers’ liability coverage.	Erivan Emmanuel Montalvo Delcompare	montalvobills6@gmail.com	Owner	Davenport	Scott	Iowa	Natalia Montalvo	Juan Portela	Signed
2215	2024-05-08 22:07	Anonymous (not verified)	94.188.207.223	Self Employed-Ryan Thornton	Proprietorship	8403 Horton Ave Urbandale IA 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-08	Ryan M Thornton	rt6366155@gmail.com	Urbandale	Polk	Iowa	April Oxendale	Bruce Thornton	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Thornton	rt6366155@gmail.com	Self	Urbandale	Polk	Iowa	April Oxendale	Bruce Thornton	Signed
1592	2023-04-22 22:46	Anonymous (not verified)	94.188.207.223	D&L painting LLC	Limited Liability Company	3109 E13th st des moines IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-22	Lenin Borjas Varela	leninborjas92@gmail.com	Des moines	Iowa	Iowa	Berenice Silva	Gustado Valdes	Signed	(1) The employer does not elect the employers’ liability coverage.	Lenin Borjas Varela	leninborjas92@gmail.com	Dueño	Clive	Iowa	Iowa	Berenice silva	Gustado Valdes	Signed
1684	2023-06-09 14:42	Anonymous (not verified)	94.188.207.223	Brandon Thomas	Proprietorship	1119 Curtiss 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.	2023-06-08	Brandon K Thomas	Brandon.thomas@countitalljoy.com.mx	Ames	IA	United States	Leah Churchill	George Trice	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandon K Thomas	Brandon.thomas@countitalljoy.com.mx	Same person	Ames	IA	United States	Leah Churchill	George Trice	Signed
1949	2023-12-11 15:20	Anonymous (not verified)	94.188.207.223	Allens construction services llc	Limited Liability Company	509 Nw Scott St Ankeny, Iowa 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-11	Allen Cheville	acsllc515@gmail.com	Ankeny	Polk	IOWA	Allen Cheville	Alexis Zimmerman	Signed	(1) The employer does not elect the employers’ liability coverage.	Allen Cheville	acsllc515@gmail.com	Self	Ankeny	Polk	IOWA	Allen Cheville	Alexis Zimmerman	Signed
1991	2024-01-17 00:34	Anonymous (not verified)	94.188.207.223	Wasabi urbandale llc	Limited Liability Company	7115 Ridgedale ct, Johnston,IA 50131	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-17	Wenhui chen	michaelchen@wasabidsm.com	Johnston	Polk	Iowa	Yilian lin	Ji jie jie	Signed	(1) The employer does not elect the employers’ liability coverage.	Wenhui chen	michaelchen@wasabidsm.com	Owner	Johnston	Polk	Iowa	Yilian lin	Ji jie jie	Signed
2115	2024-03-26 14:53	Anonymous (not verified)	94.188.207.223	DICKINSON COUNTY CLEANING AND MAINTENANCE, LLC	Limited Liability Company	414 19TH ST PO BOX 182 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.	2024-03-26	LISA ARROWOOD	lisa.arrowood1126@gmail.com	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	LISA ARROWOOD	lisa.arrowood1126@gmail.com	SELF	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1906	2023-11-14 13:47	Anonymous (not verified)	94.188.207.223	HRBC Plus	Limited Liability Company	249 SOLOMIA CT, Peosta, IA 52068	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-11	Lori S Stewart	lori@hrbcplus.com	PEOSTA	Dubuque	United States	Mark R Stewart	Danielle M Leibfried	Signed	(1) The employer does not elect the employers’ liability coverage.	Lori Stewart	lori@hrbcplus.com	Self	Peosta	Dubuque	United States	Mark R Stewart	Danielle M Peterson	Signed
1481	2023-02-24 12:45	Anonymous (not verified)	94.188.207.223	Molly Onken	Limited Liability Company	52480 HWY 210 Slater, IA. 50244	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Molly S Onken	mollyaols@gmail.com	Slater	Story	Iowa	Pamela A Wilson	Lori Konzen	Signed	(1) The employer does not elect the employers’ liability coverage.	Molly S Onken	mollyaols@gmail.com	Owner	Slater	Story	Iowa	Pamela A Wilson	Lori Konzen	Signed
2118	2024-03-27 13:25	Anonymous (not verified)	94.188.207.223	Zaragoza Home Solutions LLC	Limited Liability Company	1644 E Walnut St. Des Moines IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-27	Roberto C. Curiel	zaragozahomesolutionsllc@gmail.com	Des Moines	Polk	Iowa	Fabiola Palomares Recendiz	Francisco A Palomares Zepeda	Signed	(1) The employer does not elect the employers’ liability coverage.	Roberto C Curiel	zaragozahomesolutionsllc@gmail.com	Self	Des Moines	Polk	Iowa	Fabiola Palomares Recendiz	Francisco A Palomares Zepeda	Signed
1494	2023-03-06 08:23	Anonymous (not verified)	94.188.207.223	James Douglas Clemons	Proprietorship	3807 SW 3rd st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-06	james clemons	james.clemons@grandview.edu	des moines	Iowa	United States	james clemons	james clemons	Signed	(1) The employer does not elect the employers’ liability coverage.	james clemons	james.clemons@grandview.edu	myself	des moines	Iowa	United States	james clemons	james clemons	Signed
1817	2023-08-24 12:29	Anonymous (not verified)	94.188.207.223	Global Roofing LLC	Limited Liability Company	504 Heritage Rd Cedar Falls IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-20	Jose Rafael Delgado Marin	grjrd808504@outlook.com	Cedar Falls	Black Hawk	Iowa	Noemi Guerrero	Andres B Montoya	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Rafael Delgado	grjrd808504@outlook.com	member	Cedar Falls	Black Hawk	Iowa	Noemi Guerrero	Andres B Montoya	Signed
2029	2024-02-07 09:51	Anonymous (not verified)	94.188.207.223	Jorge Llanos	Proprietorship	3304 Le Mesa Way, South Sioux City, NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-07	Jorge Llanos	jorge.llanos123708@gmail.com	South Sioux City	Dakota	Nebraska	Jordan Nisiewicz	Cody Dunbar	Signed	(1) The employer does not elect the employers’ liability coverage.	Monica Acosta	macosta@leafhome.com	Recruiter	Sioux Falls	Minnehaha	South Dakota	Cody Dunbar	Jordan Nisiewicz	Signed
1729	2023-07-09 15:33	Anonymous (not verified)	94.188.207.223	Melvin A mineros	Limited Liability Company	6209 Windsor dr des moines IA 50312	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-09	Melvin A mineros	minerosframing.llc@gmail.com	Des moines	Polk	IA	Orlando dominguez	Isaac salazar	Signed	(1) The employer does not elect the employers’ liability coverage.	Jaime leiva	jaime@boersmaninsurance.com	Agent	Des moines	Polk	IA	Narciso hidalgo	Balmore perez	Signed
1737	2023-07-11 08:32	Anonymous (not verified)	94.188.207.223	Scornos waukee llc	Limited Liability Company	286 w hickman rd waukee iowa 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-11	Gary Fatino	fatinomarketinggroup@yahoo.com	des moines	polk	iowa	Liana Fatino	Gary Fatino	Signed	(1) The employer does not elect the employers’ liability coverage.	Gary Fatino	fatinomarketinggroup@yahoo.com	owner	des moines	polk	iowa	Liana Fatino	Gary Fatino	Signed
1971	2023-12-29 19:27	Anonymous (not verified)	94.188.207.223	Megan Thibodeau	Proprietorship	4301 Adams Ave, Des Moines, IA 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-29	Megan E Thibodeau	megancallan@hotmail.com	Des Moines	Iowa	United States	Travis Releford	Courtney Releford	Signed	(1) The employer does not elect the employers’ liability coverage.	Megan E Thibodeau	megancallan@hotmail.com	Self	Des Moines	Iowa	United States	Travis Releford	Courtney Releford	Signed
1864	2023-10-09 09:52	Anonymous (not verified)	94.188.207.223	Admiral Staffing Inc	Limited Liability Company	580 8th Ave, 15th Floor, New York NY 10018	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-09	Rezwan Rafeek	ray@admiralstaffinginc.com	23 Catalpa Lane	Valley Stream	NY	Ikbal Sherif	Salim Balee	Signed	(1) The employer does not elect the employers’ liability coverage.	Shafi Rafeek	shafi@admiralstaffinginc.com	Office Manager	New York	NY	United States	Ikbal Sherif	Salin Balee	Signed
1724	2023-07-06 19:34	Anonymous (not verified)	94.188.207.223	ALDO B. CANCINO HERNANDEZ	Proprietorship	2524 SHADOW CREEK LN, DES MOINES, IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-06	ALDO B. CANCINO HERNANDEZ	aldo94.cansino@gmail.com	DES MOINES	USA	IOWA	JUAN M. MAYORGA	OFELIA BUSTILLOS VALENZUELA	Signed	(1) The employer does not elect the employers’ liability coverage.	ALDO B. CANCINO HERNANDEZ	aldo94.cancino@gmail.com	SELF	DES MOINES	USA	IOWA	JUAN M. MAYORGA	OFELIA BUSTILLOS VALENZUELA	Signed
1612	2023-04-27 10:37	Anonymous (not verified)	94.188.207.223	Grind Works LLC	Proprietorship	26416 289th place Unit H Adel IA 50003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-27	Adam Samuelson	Hello@grindworksia.com	Adel	Dallas	Iowa	Chandler Clark	Adam Samuelson	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Samuelson	Hello@Grindowrksia.com	N/A	Adel	Dallas	Iowa	Adam Samuelson	Chandler Clark	Signed
1681	2023-06-08 15:55	Anonymous (not verified)	94.188.207.223	Cross Roads Builders, LLC	Limited Liability Company	3103 21st Street Camanche, IA.52730	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-08	Mark Allan Cross	rcreek2016@gmail.com	Davenport	iowa	United States	Barb Deering	Mike Cross	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Cross	rcreek2016@gmail.com	Owner/President	Davenport	IA	United States	Barb Deering	Mike Cross	Signed
1600	2023-04-25 14:38	Anonymous (not verified)	94.188.207.223	martin garcia	Proprietorship	219 austin st sw cedar rapids iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-25	martin garcia ayala	martingarcia2100@gmail.com	cedar rapids	linn	iowa	Ryan Klein	Karina Jacobson	Signed	(1) The employer does not elect the employers’ liability coverage.	martin garcia ayala	martingarcia2100@gmail.com	na	cedar rapids	linn	iowa	Ryan Klein	Karina Jacobson	Signed
1666	2023-05-28 15:57	Anonymous (not verified)	94.188.207.223	Projects Under Development LLC	Limited Liability Company	2516 Hickory Grove Rd Davenport Iowa 52804	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-29	James Stock	jamese1053@gmail.com	Davenport	Scott	Ia	Ronald Lang	Karen Walker	Signed	(1) The employer does not elect the employers’ liability coverage.	James Stock	jamese1053@gmail.com	Owner	Davenport	Scott	Ia	Ronald Lang	Karen Walker	Signed
1719	2023-07-01 21:34	Anonymous (not verified)	94.188.207.223	Granite & More	Limited Liability Company	4730 Tremont ave Davenport Iowa 52807	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-01	Hong Le	granite732@yahoo.com	Davenport	Scott	Iowa	Jin Chen	Betty Song	Signed	(1) The employer does not elect the employers’ liability coverage.	Jin Chen	clteam563@gmail.com	Manager	Bettendorf	Scott	Iowa	Jin Chen	Betty Song	Signed
1523	2023-03-18 13:15	Anonymous (not verified)	94.188.207.223	Aguilera’s Lawn Care LLC	Limited Liability Company	827 17th Street Southeast, Altoona, 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.	2023-03-18	Jose Aguilera	aguileramowing20@gmail.com	Altoona	IA	United States	Heather Aguilera	Heather Aguilera	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Aguilera	aguileramowing20@gmail.com	Self- owner	Altoona	IA	United States	Heather Aguilera	Heather Aguilera	Signed
1526	2023-03-21 12:24	Anonymous (not verified)	94.188.207.223	Quad Cities Transport Inc	Proprietorship	1106 46th ave Rock Island IL 61201	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-21	Howard Davis	qctranaportinc@gmail.com	East Moline	Rock Island	Illinois	Ricky Oconner	Patrick Watkins	Signed	(1) The employer does not elect the employers’ liability coverage.	Howard Davis	hdenterprisesinc14@gmail.com	Owner	East Moline	Rock Island	Illinois	Patrick Watkins	Ricky Oconner	Signed
1629	2023-05-09 08:50	Anonymous (not verified)	94.188.207.223	Alex Jones	Proprietorship	2423 Glass Road Northeast, Cedar Rapids, IA 52402, United State	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-09	Alex Jones	ajones0425@yahoo.com	Cedar Rapids	Linn	Iowa	Jordan Nisiewicz	Charles Wood	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Jordan Loyd	Charles Wood	Signed
1503	2023-03-07 12:45	Anonymous (not verified)	94.188.205.177	Al's Roofing LLC	Limited Liability Company	P O Box 277 Lime Springs, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-18	John Martin	darrele@ciains.biz	Lime Springs	Howard	Iowa	Darrel Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Al's Roofing LLC	darrele@ciains.biz	agent	Lime Springs	Howard	Iowa	Darrel Elsbernd	Chris Fye	Signed
2077	2024-03-06 11:08	Anonymous (not verified)	94.188.205.177	Randy's all Right painting	Proprietorship	24531n.ave Dallas center iowa po 445	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-06	David keasey	keaseyshideaway@gmail.com	Dallas center	Dallas	Iowa	Angela Johnston	Robin Vilz	Signed	(1) The employer does not elect the employers’ liability coverage.	David keasey	keaseyshideaway@gmail.com	Self	Dallas center	Dallas	Iowa	Angela Johnston	Robin Volz	Signed
1999	2024-01-25 16:57	Anonymous (not verified)	94.188.205.177	Nicholas Schaff	Limited Liability Company	6934 rolling ridge ct sw cedar rapids Iowa 52404	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-25	Nicholas Schaff	schaff.lawncare@gmail.com	cedar rapids	linn	iowa	Brian Zeller	Cassie Schaff	Signed	(1) The employer does not elect the employers’ liability coverage.	Nicholas schaff	schaff.lawncare@gmail.com	Same person	cedar rapids	iowa	iowa	Brian zeller	cassie schaff	Signed
1579	2023-04-17 17:00	Anonymous (not verified)	94.188.205.177	Home provisions siding LLC	Limited Liability Company	1816 Francis avenue apt 1	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-17	Luis Alberto Ramirez Mendez	luisramirez4308@icloud.com	Desmoines	Polk	Iowa	Alexandra Gomez-Benitez	Marcedez ramirez	Signed	(1) The employer does not elect the employers’ liability coverage.	Luis Alberto Ramirez Mendez	luisramirez4308@icloud.com	None	Des Moines	Polk	Iowa	Alexandra Gomez-Benitez	Marcedez Roxana Ramirez	Signed
2103	2024-03-18 12:33	Anonymous (not verified)	94.188.205.177	Scornos 1973 Inc	Proprietorship	8561 hickman rd urbandale iowa 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-18	Liana Fatino	lfatino@yahoo.com	des moines	POLK	IOWA	GARY FATINO	LISA VACCO	Signed	(1) The employer does not elect the employers’ liability coverage.	GARY FATINO	lfatino@yahoo.com	husband	des moines	polk	iowa	Gary Fatino	Lisa Vacco	Signed
1638	2023-05-11 07:33	Anonymous (not verified)	94.188.205.177	HV Drywall LLC	Proprietorship	1991 Holiday Rd, Coralville, IA 52241	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-11	Jose Jesus Hernandez	jh80292@gmail.com	Coralville	Johnson	Iowa	Arcel Servin	Chris Hay	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Jesus Hernandez	jh80292@gmail.com	self	Coralville	Johnson	Iowa	Arcel Servin	Chris Hay	Signed
1511	2023-03-09 15:52	Anonymous (not verified)	94.188.205.177	CG Welding	Limited Liability Company	5400 147th	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-09	Christopher A Lendt	weldingiowa@gmail.com	Urandale	Dallas	IA	Chris Lendt	Chris Lendt	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher A Lendt	weldingiowa@gmail.com	Owner	Urandale	Dallas	IA	Christopher Lendt	Christopher Lendt	Signed
1921	2023-11-22 12:14	Anonymous (not verified)	94.188.205.177	Julie Drtina	Proprietorship	Cresco Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-22	Julie Drtina	juliedrtina@hotmail.com	Cresco	Howard	Iowa	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Julie Drtina	juliedrtina@hotmail.com	self	Cresco	Howard	Iowa	Chris Fye	Darrel Elsbernd	Signed
1897	2023-11-06 09:12	Anonymous (not verified)	94.188.205.177	Matthew Jones	Limited Liability Company	124 NE 49th Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-06	Matthew Jones	mjj4242@gmail.com	Ankeny	Polk	IA	Duan Willform	AJ Giebelstein	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Jones	mjj4242@gmail.com	Self	Ankeny	Polk	IA	AJ Giebelstein	Duan Willform	Signed
2127	2024-03-29 09:50	Anonymous (not verified)	94.188.205.177	Peterson Home Improvement, LLc	Limited Liability Company	31451 510th Street Russ	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-29	Paul M Peterson	petersonhomeimprovementllc@gmail.com	Russell	Iowa	Iowa	Peggy Jo Peterson	Matthew Peterson	Signed	(1) The employer does not elect the employers’ liability coverage.	Peggy Peterson	petersonhomeimprovementllc@gmail.com	Husband	Russell	Lucas	Iowa	Paul M Peterson	Matthew Peterson	Signed
1499	2023-03-07 11:21	Anonymous (not verified)	94.188.205.177	Ryan Zimmerman	Proprietorship	17606 35th St Lime Springs, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-27	Ryan Zimmerman	darrele@ciains.biz	Lime Springs	Howard	Iowa	Darrel Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Darrel Elsbernd	darrele@ciains.biz	agent	Lime Springs	Howard	Iowa	Darrel Elsbernd	Chris Fye	Signed
1766	2023-07-28 09:33	Anonymous (not verified)	94.188.205.177	Kleckner Trucking LLC	Limited Liability Company	3780 March Ave Osage, IA 50461	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-28	Tracy Kleckner	klecknertrucking8710@hotmail.com	Osage	Mitchell	Iowa	Nicole Kleckner	Tanya Kleckner	Signed	(1) The employer does not elect the employers’ liability coverage.	L.R. Falk Construction	jeannie@lrfalk.com	dump truck hauler	Osage	Mitchell	Iowa	Nicole Kleckner	Tanya Kleckner	Signed
2000	2024-01-26 10:05	Anonymous (not verified)	94.188.205.177	Nick Myers Construction	Proprietorship	4736 Candlewick Drive, 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.	2024-01-26	Nicholas Myers	myersnicholasj@gmail.com	Norwalk	Warren	Iowa	John Myers	Brenda Myers	Signed	(1) The employer does not elect the employers’ liability coverage.	Nicholas Myers	nickmyersconstruction@gmail.com	Owner	Norwalk	IA	IA	John Myers	Brenda Myers	Signed
1550	2023-03-31 13:35	Anonymous (not verified)	94.188.205.177	Nadarevic Group LLC	Limited Liability Company	3633 NW 177th Ct, Clive, IA 50325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-31	Ajdin Nadarevic	ajdin@silverstonedevgroup.com	Clive	Dallas	Iowa	Jeremy Boysen	Brooke Boysen	Signed	(1) The employer does not elect the employers’ liability coverage.	Ajdin Nadarevic	ajdin@silverstonedevgroup.com	Owner	Clive	Dallas	Iowa	Jeremy Boysen	Brooke Boysen	Signed
1893	2023-11-02 14:39	Anonymous (not verified)	94.188.205.177	Dagoberto Nuñez	Proprietorship	Iowa city	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-02	Dagoberto Nuñez	nunezdagoberto730@gmail.com	833 basswood ln iowa city	Johnson	IA	Darwin salgado	Ramon nuñez	Signed	(1) The employer does not elect the employers’ liability coverage.	Dagoberto Nuñez	nunezdagoberto730@gmail.com	Yo mismo	Iowa city	Johnson	IA	Darwin Salgado	Ramon nuñez	Signed
1632	2023-05-09 11:10	Anonymous (not verified)	94.188.205.177	MM Drywall LLC Moises Melo Santiago	Proprietorship	7500 Bloomfield Road Lot 78	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-01	Moises Melo Santiago	deb@piciowa.com	Des Moines	Polk	Iowa	kelly Denger	Debra Stratton	Signed	(1) The employer does not elect the employers’ liability coverage.	MM Drywall LLC Moises Melo Santiago	deb@piciowa.com	self	Des Moines	polk	Iowa	Kelly Denger	Debra Stratton	Signed
2018	2024-02-01 15:23	Anonymous (not verified)	94.188.205.177	SolQ, LLC	Limited Liability Company	184 N 100 E STE A Logan, UT 84321	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-01	David Bean	dave@solq.com	Clarkston	Cache	Utah	Perry M. Koger	Rebecca Koger	Signed	(1) The employer does not elect the employers’ liability coverage.	David Bean	dave@solq.com	Owner	Logan	Cache	Utah	Perry M. Koger	Rebecca Koger	Signed
2162	2024-04-18 19:25	Anonymous (not verified)	94.188.205.177	Escobar Enterprises, LLC	Limited Liability Company	125 East Broad Street, 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.	2024-04-18	Jesse Escobar	jesse@escobar-enterprises.com	Des Moines	Polk	Iowa	Rene Mauricio Martinez	Jessa Caitlin Marfal	Signed	(1) The employer does not elect the employers’ liability coverage.	Jesse Escobar	jesse@escobar-enterprises.com	owner	Des Moines	Polk	Iowa	Rene Mauricio Martinez	Jessa Caitlin Marfal	Signed
1553	2023-04-04 14:52	Anonymous (not verified)	94.188.205.177	TOPSOIL OUTDOOR SERVICES	Limited Liability Company	4919 SCHUBERT ST	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-04	LIBAN	topsoiloutdoor@gmail.com	AMES	IA	United States	Liban Wetzberger	Liban Wertzberger	Signed	(1) The employer does not elect the employers’ liability coverage.	Liban Wertzberger	topsoiloutdoor@gmail.com	Owner	AMES	IA	United States	Liban Wertzberger	Liban Wertzberger	Signed
1884	2023-10-27 18:32	Anonymous (not verified)	94.188.205.177	J&M dry wall	Proprietorship	948 Kern St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-27	Melecio Zacarias-Cano	Meleciozacarias29@gmail.com	Waterloo	Black hawk	IA	Luis flores	Luis flores	Signed	(1) The employer does not elect the employers’ liability coverage.	Melecio Zacarias-Cano	Meleciozacarias29@gmail.com	Self	Waterloo	Black hawk	IA	Luis Flores	Luis flores	Signed
2167	2024-04-21 22:01	Anonymous (not verified)	94.188.205.177	The Duerson Corportaion	Proprietorship	601 1st Ave N, 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.	2024-04-21	Nicholas John Myers	myersnicholasj@gmail.com	Norwalk	IA	United States	Theresa Myers	Bradyn Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Nicholas John Myers	myersnicholasj@gmail.com	Owner	Norwalk	IA	United States	Theresa Myers	Bradyn Smith	Signed
1748	2023-07-17 06:35	Anonymous (not verified)	94.188.205.177	Westys paint and stain llc	Limited Liability Company	1961 150th st waverly, ia 50677	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-17	Kaitlin westendorf	westyspaint@gmail.com	Waverly	Bremer	Iowa	Kathy westendorf	Michael westendorf	Signed	(1) The employer does not elect the employers’ liability coverage.	Westys paint & stain llc	westyspaint@gmail.com	Owner	Waverly	Bremer	Iowa	Kathy westendorf	Michael westendorf	Signed
2141	2024-04-09 09:34	Anonymous (not verified)	94.188.205.177	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln Street Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-09	James Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Kathryn Kelley	Janice Henningsen	Signed	(1) The employer does not elect the employers’ liability coverage.	James Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Kathryn Kelley	Janice Henningsen	Signed
1485	2023-02-25 18:14	Anonymous (not verified)	94.188.205.177	J&V painting	Limited Liability Company	4759 woodland AV #56 West Des moines IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-25	Jessika Romero	jony.bel.vla@gmail.com	West Des Moines	Polk	Ia	Samir rahmanovic	Samir rahmanovic	Signed	(1) The employer does not elect the employers’ liability coverage.	Jessika Romero	jony.bel.vla@gmail.com	Self	West Des Moines	Polk	IA	Samir Rahmanovic	SAMIR RAHMANOVIC	Signed
1828	2023-09-06 14:43	Anonymous (not verified)	94.188.205.177	Des Moines Smart Solutions LLC.	Proprietorship	1329 56th st, Des Moines, IA 50311, United States	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-06	Denzel Colocho	alejandro_colcho@yahoo.com	Des Moines, IA	Polk	Iowa	Jordan Nisiewicz	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	MO	Jordan Loyd	Charles Wood	Signed
1966	2023-12-27 13:17	Anonymous (not verified)	94.188.205.177	Jake Borntreger	Proprietorship	50 Stone St Clermont, 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.	2022-02-25	Jake Borntreger	darrele@ciains.biz	Clermont	Fayette	Iowa	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jake Borntreger	darrele@ciains.biz	self	Clermont	Fayette	Iowa	Chris Fye	Darrel Elsbernd	Signed
1486	2023-02-26 17:53	Anonymous (not verified)	94.188.205.177	TURNER LAWN CARE	Limited Liability Company	16493 185th 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.	2023-02-27	JEFF TURNER	jscturner2626@gmail.com	MILO	IA	United States	Tim Borrall	BONNIE BORRALL	Signed	(1) The employer does not elect the employers’ liability coverage.	SHARON RENEE TURNER	jscturner2626@gmail.com	wife	MILO	IA	United States	Tim Borrall	BONNIE BORRALL	Signed
2063	2024-02-29 10:12	Anonymous (not verified)	94.188.205.177	Geral Lee Pattison	Proprietorship	22127 Hwy 52	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-29	Geral Lee Pattison	pattisonglee@gmail.com	GARNAVILLO	IA	IA	Lee Zapf	Andrew Corllet	Signed	(1) The employer does not elect the employers’ liability coverage.	Geral Lee Pattison	pattisonglee@gmail.com	Self	GARNAVILLO	IA	IA	Lee Zapf	Andrew Corllet	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
1844	2023-09-14 14:15	Anonymous (not verified)	94.188.205.177	Royal Gutters & Construction, LLC	Limited Liability Company	1420 120th Street, Hazleton, IA 50641	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-01	Andy Hershberger	hershbergera@gmail.com	Hazleton	Buchanan	Iowa	Eli Raber	Steve Frost	Signed	(1) The employer does not elect the employers’ liability coverage.	Andy Herschberger	hershbergera@gmail.com	self	Hazleton	Buchanan	Iowa	Eli Miller	Steve Frost	Signed
1581	2023-04-18 14:04	Anonymous (not verified)	94.188.205.177	L&J Services LLC	Limited Liability Company	6 highland acres rd marshalltown iowa 50158	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-18	Josh Colwell	centraliowa@fibrenew.com	Marshalltown	IA	United States	Micah Hesse	Hunter Bolinsger	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Colwell	centraliowa@fibrenew.com	Owner	Marshalltown	IA	United States	Micah Hesse	Hunter Bolsinger	Signed
1830	2023-09-08 11:45	Anonymous (not verified)	94.188.205.177	Bradley A Sneeden	Proprietorship	36 Sunset Drive, Beardstown, IL 62618	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-08	Bradley A Sneeden	bradsneeden@gmail.com	Beardstown	Cass	IL	Billie Sneeden	Dillon McNeff	Signed	(1) The employer does not elect the employers’ liability coverage.	Bradley A Sneeden	bradsneeden@gmail.com	Self	Beardstown	Cass	IL	Billie Sneeden	Dillon McNeff	Signed
1582	2023-04-18 14:04	Anonymous (not verified)	94.188.205.177	L&J Services LLC	Limited Liability Company	6 highland acres rd marshalltown iowa 50158	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-18	Josh Colwell	centraliowa@fibrenew.com	Marshalltown	IA	United States	Micah Hesse	Hunter Bolinsger	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Colwell	centraliowa@fibrenew.com	Owner	Marshalltown	IA	United States	Micah Hesse	Hunter Bolsinger	Signed
2179	2024-04-25 10:58	Anonymous (not verified)	94.188.205.177	Loonpa Landscaping LLC	Limited Liability Partnership	5309 Red Oak Ln Cedar Falls, IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2024-04-25	Brent Barloon	Brent@barerootslawn.care	WAterloo	Black Hawk	Iowa	James White	Kari White	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Daniel White	danny@barerootslawn.care	Owner	Cedar Falls	Black Hawk	Iowa	James White	Kari White	Signed
1565	2023-04-11 09:49	Anonymous (not verified)	94.188.205.177	Leonard Moss Roofing	Proprietorship	2018 Superior Street, Webster City, Iowa 50595	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-11	Leonard Moss	leonard.moss48@gmail.com	Webster City	Hamilton	Iowa	Vicky Hahne	Morgan Jensen	Signed	(1) The employer does not elect the employers’ liability coverage.	Leonard Moss	leonard.moss48@gmail.com	Same	Webster City	Hamilton	Iowa	Vicky Hahne	Morgan Jensen	Signed
1567	2023-04-12 10:01	Anonymous (not verified)	94.188.205.177	Hearts on fire llc	Limited Liability Partnership	931 14th Ave Se Altoona Iowa 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.	2023-04-12	Matt Moffet	dsm@fibrenew.com	Altoona	Polk	Iowa	Jason McDowell	Mike Wennekamp	Signed	(1) The employer does not elect the employers’ liability coverage.	Matt Moffet	dam@fibrenew.com	Owner	Altoona	Polk	Iowa	Jason McDowell	Mike Wennekamp	Signed
1709	2023-06-26 14:55	Anonymous (not verified)	94.188.205.177	Jeremy Pledge	Proprietorship	3310 East Washington Street, Iowa City, IA 52245	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-26	Jeremy Pledge	worknoplay8@gmail.com	Iowa City, IA	Johnson County	Iowa	Jordan Nisiewicz	Charles Wood	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Charles Woods	Jordan Loyd	Signed
1484	2023-02-25 16:42	Anonymous (not verified)	94.188.205.177	Carpenter wood shed/ rays longging	Limited Liability Company	1631 230th st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-27	Raymond Carpenter	corinnafrymoyer@gmail.com	tipton	Cedar	Iowa	corinna frymoyer	Levi carpenter	Signed	(1) The employer does not elect the employers’ liability coverage.	Raymond Carpenter	corinnafrymoyer@gmail.com	Self	Tipton	Cedar	Iowa	Corinna frymoyer	Levi carpenter	Signed
1733	2023-07-10 14:30	Anonymous (not verified)	94.188.205.177	Leaf home	Proprietorship	1595 Georgetown Rd., Hudson, OH 44236	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-10	Andrew Koske	aokoz_23@outlook.com	East Moline	IL	United States	Andrew Koske	Andrew Koske	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Koske	aokoz_23@outlook.com	None	East Moline	IL	United States	Andrew Koske	Andrew Koske	Signed
1823	2023-08-29 12:46	Anonymous (not verified)	94.188.205.177	A&S Construction LLC	Proprietorship	5920 Village Circle Johnston IA 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-28	Admir Omerovic	sabinamur22@icloud.com	5920 Village Circle	Polk	IA	Kelly Coluzzi	Erick Schuldt	Signed	(1) The employer does not elect the employers’ liability coverage.	Admir Omerovic	sabinamu22@icloud.com	Owner	Johnston	Polk	IA	Kelly Coluzzi	Erick Schuldt	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
2098	2024-03-15 18:38	Anonymous (not verified)	94.188.205.177	OMG Bros, LLC	Limited Liability Partnership	404 Ivanhoe Rd, Waterloo, IA 50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2024-03-15	Oscar Omar Gaytan	og210666@gmail.com	Waterloo	Black Hawk	Iowa	Kaden Lyle	Jake Usher	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Tristan Anthony Siebrands	omgservices@omgbros.org	Partner	Waterloo	Black Hawk	Iowa	Kaden Lyle	Jake Usher	Signed
1524	2023-03-20 09:00	Anonymous (not verified)	94.188.205.177	David Roman	Proprietorship	8350 EP True Parkway, Apt 1101, 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.	2023-03-20	David Roman	vida8147@gmail.com	West Des Moines	Dallas	IA	Dario Lucas Barrera	Alfonso Montoya	Signed	(1) The employer does not elect the employers’ liability coverage.	David Roman	vida8147@gmail.com	Self	West Des Moines	Dallas	IA	Dario Lucas Barrera	Alfonso Montoya	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
1819	2023-08-26 00:50	Anonymous (not verified)	94.188.205.177	JnP Enterprise LLC D/B/A/ JnP Trucking	Limited Liability Company	110 Elizabeth St W Grand Junction, IA. 50107	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-26	Patrick Cook	pat@jnp-enterprise.com	Grand Junction	Iowa	United States	Mary J Mack	Hayden M Cook	Signed	(1) The employer does not elect the employers’ liability coverage.	Patrick Cook	pat@jnp-enterprise.com	50% Member, Owner, Operator	Grand Junction	Iowa	United States	Mary J Mack	Hayden M Cook	Signed
1660	2023-05-24 10:11	Anonymous (not verified)	94.188.205.177	Might Lawn Care	Limited Liability Company	1920 W 70th St. Davenport, IA 52806	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-24	Meredith Whitney Might	mightlawncare@gmail.com	Davenport	Scott	IA	Samuel Lawrence Might	Suzette Henriksen	Signed	(1) The employer does not elect the employers’ liability coverage.	Meredith Might	mightlawncare@gmail.com	Owner	Davenport	Scott	IA	Samuel Lawrence Might	Suzette Henriksen	Signed
1614	2023-04-27 15:18	Anonymous (not verified)	94.188.205.177	Crawford Construction Services LLC	Limited Liability Company	1018 Creston Ave, Des Moines, Ia 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-27	Casey D Crawford	crawfordcasey8824@gmail.com	Des Moines	Polk	Iowa	Nicole Powell	Steve Crawford	Signed	(1) The employer does not elect the employers’ liability coverage.	Casey D Crawford	crawfordcasey8824@gmail.com	Owner	Des Moines	Polk	Iowa	Nicole Powell	Steve Crawford	Signed
1853	2023-09-26 10:16	Anonymous (not verified)	94.188.205.177	Saketh Mahavadi	Limited Liability Company	294 s 83rd street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-26	Saisaketh	sakethmahavadi@gmail.com	West Des Moines	IA	United States	David Chan	Ahnaf Yeasin	Signed	(1) The employer does not elect the employers’ liability coverage.	David Chan	Davidchan8873@gmail.com	Business Partner	West Des Moines	IA	United States	Saketh Mahavadi	Ahnaf Yeasin	Signed
1868	2023-10-16 12:36	Anonymous (not verified)	94.188.205.177	North Bay Dock Service, LLC	Limited Liability Company	PO Box 374, 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.	2023-10-16	Teresa A. JOhnson	NBDSLLC@gmail.com	Spirit Lake	Dickinson	Iowa	Michael Chozen	April Bosma	Signed	(1) The employer does not elect the employers’ liability coverage.	Teresa Johnson	NBDSLLC@gmail.com	Manager	Spirit Lake	Dickinson	Iowa	Michael Chozen	April Bosma	Signed

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