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:
565	2021-07-08 13:42	Anonymous (not verified)	173.25.132.255	Communications Construction Services LLC	Limited Liability Company	1315 East 38th 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.	2021-07-08	John McCann Jr	communicationconstructionllc@gmail.com	Des Moines	IA	United States	Laura McCann	David Garza	Signed	(1) The employer does not elect the employers’ liability coverage.	Laura McCann	communicationconstructionllc@gmail.com	spouse	Des Moines	IA	United States	John J McCann Jr	David Christopher Garza III	Signed
1415	2023-01-09 10:50	Anonymous (not verified)	73.103.30.27	MWK Solutions, LLC	Limited Liability Company	1001 South Park St., Fairfield, IA 52556	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-09	Michael Wayne Koch	mwkpar@gmail.com	Fairfield	Jefferson	Iowa	Ann Koch	David Fleming	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Wayne Koch	mwkpar@gmail.com	Self	Fairfield	Jefferson	Iowa	Ann Koch	David Fleming	Signed
2061	2024-02-28 14:16	Anonymous (not verified)	94.188.205.166	Cael Gulrud	Proprietorship	206 W Main 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.	2024-02-28	Cael Gulrud	gulrud8728@gmail.com	Calmar	IA	United States	Belle Olsgard	David Gulrud	Signed	(1) The employer does not elect the employers’ liability coverage.	Cael Gulrud	gulrud8728@gmail.com	Me	Calmar	IA	United States	Belle Olsgard	David Gulrud	Signed
2046	2024-02-15 11:29	Anonymous (not verified)	94.188.205.175	Ervin Cabrera Mendez	Proprietorship	4822 Meadowlark Lane, Sioux City, Iowa 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.	2023-01-01	Ervin Cabrera Mendez	ervincabrera89@gmail.com	Sioux City	Woodbury	Iowa	Kyle Buum	David Jacobs	Signed	(1) The employer does not elect the employers’ liability coverage.	Ervin Cabrera Mendez	ervincabrera89@gmail.com	Owner	Sioux City	Woodbury	Iowa	Kyle Buum	David Jacobs	Signed
2049	2024-02-16 09:19	Anonymous (not verified)	94.188.205.169	Cadona Construction LLC	Limited Liability Company	215 S Leonard, Sioux City, IA 51103	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Luis Cardona	luiscardona5151@gmail.com	Sioux City	Woodbury	Iowa	Kyle Buum	David Jacobs	Signed	(1) The employer does not elect the employers’ liability coverage.	Luis Cardona	luiscardona5151@gmail.com	Owner	Sioux City	Woodbury	Iowa	Kyle Buum	David Jacobs	Signed
281	2020-10-20 08:58	Anonymous (not verified)	136.37.174.39	Merge Midwest Engineering, LLC	Limited Liability Company	2668 W Catalpa Street, Olathe, KS 66061	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Michael Lee Baer	lbaer@mergemidwest.com	Louisburg	Miami	Kansas	Heather Lee Baer	Ami Bowes	Signed	(1) The employer does not elect the employers’ liability coverage.	Janelle Marie Clayton	jclayton@mergemidwest.com	Self	Olathe	Johnson	Kansas	Patrick McCartney	David Jahner	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
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
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
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
1142	2022-06-03 21:35	Anonymous (not verified)	66.43.196.246	Doug ayers	Proprietorship	808 Willow st Dumont Iowa 50625	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-03	Doug dale ayers	dougayers2612@gmail.com	Dumont	Butler	Iowa	Amy Pcha	David Shear	Signed	(1) The employer does not elect the employers’ liability coverage.	Doug ayers	dougayers2612@gmail.com	Owner operator	Dumont	Butler	Iowa	Amy Picha	David Shear	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
266	2020-09-21 18:08	Anonymous (not verified)	174.126.94.77	Club Fantasy Inc.	Limited Liability Company	P.O. Box 5115 Sioux City Iowa 51102	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-21	Curtis A. Behr	cacbehr@aol.com	Sioux City	Woodbury	Iowa	Carter Vahle	Dawn Meyer	Signed	(1) The employer does not elect the employers’ liability coverage.	Curtis A. Behr	cacbehr@aol.com	Self	Sioux City	Woodbury	Iowa	Carter Vahle	Dawn Meyer	Signed
1183	2022-07-06 13:43	Anonymous (not verified)	50.82.95.247	2DL Construction, LLC	Limited Liability Company	1134 21st Street, Des Moines, IA 50311	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-06	Diego Lopez	calihernandez01@icloud.com	Des Moines	Polk	Iowa	Ryan Johnson	Deanna Yersin	Signed	(1) The employer does not elect the employers’ liability coverage.	Diego Lopez	calihernandez01@icloud.com	Self	Des Moines	Polk	Iowa	Ryan Johnson	Deanna Yersin	Signed
1290	2022-09-01 15:29	Anonymous (not verified)	198.14.221.176	DR. WAYNE HAIDSIAK ii and Dr. Junior Hensley DBA Tri County Veterinary Service	Partnership	101 170TH ST CLEARFIELD IA 50840	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Dr. Wayne Haidsiak II	insurance@ringgoldins.com	Lenox	Taylor	IA	Amy Ford	Deb Davenport	Signed	(1) The employer does not elect the employers’ liability coverage.	Dr. J.D. Hensley	insurance@ringgoldins.com	Partner	Cleafield	Taylor	IA	Amy Ford	Deb Davenport	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
2206	2024-05-07 09:10	Anonymous (not verified)	94.188.205.166	Stephanie Farmer	Proprietorship	600 6th Ave, Marion, IA 52302	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Stephanie Farmer	farmer.stephanie22@gmail.com	Marion	Linn	IA	Chris Farmer	Deb Hartz	Signed	(1) The employer does not elect the employers’ liability coverage.	Stephanie Farmer	farmer.stephanie22@gmail.com	Self	Marion	Linn	IA	Chris Farmer	Deb Hartz	Signed
340	2020-12-18 08:37	Anonymous (not verified)	172.83.31.129	Todd Fisher DBA Lake Country Window Cleaning	Proprietorship	1506 Willow Place, Clear Lake, IA 50428	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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.	2020-12-18	Todd Fisher	Lakecountrywindow@yahoo.com	Clear Lake	Cerro Gordo	Iowa	Matt Koch	Deb Koch	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Todd Fisher	lakecountrywindow@yahoo.com	Same	Clear Lake	Cerro Gordo	Iowa	Matt Koch	Deb Koch	Signed
912	2022-02-14 17:51	Anonymous (not verified)	72.168.160.122	Mark Weiss	Proprietorship	11461 NW Timber Way Granger Iowa 50109	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-14	Mark Weiss	kkweiss77@yahoo.com	Granger	Polk	Iowa	Paul Ness	Deb Ness	Signed	(1) The employer does not elect the employers’ liability coverage.	Casi Sparks	csparks@destinyhomesusa.com	Subcontractor	Waukee	Dallas	Iowa	Paul Ness	Deb Ness	Signed
2065	2024-02-29 13:53	Anonymous (not verified)	94.188.205.166	LEONARD BOUGHTON	Partnership	1616 AGENCY ST, BURLINGTON, IOWA 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.	2024-02-29	LEONARD L BOUGHTON	firstrate96@yahoo.com	BURLINGTON	DES MOINES	IOWA	PAM ZIPPE	DEB SCOTT	Signed	(1) The employer does not elect the employers’ liability coverage.	LEONARD L BOUGHTON	firstrate96@yahoo.com	Owner	BURLINGTON	DES MOINES	IOWA	PAM ZIPPE	DEB SCOTT	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
310	2020-11-09 13:32	Anonymous (not verified)	75.89.78.93	CA Smith LLC	Limited Liability Company	805 N Hayes Street Mount Ayr, Iowa 50854	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-11-01	CA Smith LLC	smithoil.cs@gmail.com	Mount Ayr	Ringgold	Iowa	Wm H French	Deborah Creveling	Signed	(1) The employer does not elect the employers’ liability coverage.	CA Smith LLC	smithoil.cs@gmail.com	Self	Mount Ayr	Ringgold	Iowa	Wm H French	Deborah Creveling	Signed
262	2020-09-18 13:54	Anonymous (not verified)	75.162.229.152	Morgan Group LLC	Limited Liability Company	1124 7th St. West Des Moines, IA 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-18	Mackinley Charles Morgan	MORGANGROUPLLC@GMAIL.COM	West Des Moines	Polk	Iowa	Mark Steven Morgan	Deborah Renee 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	Mark Steven Morgan	Deborah Renee Morgan	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
2153	2024-04-15 21:59	Anonymous (not verified)	94.188.205.167	Ethan M Hoffman	Proprietorship	1442 N. County RD 800, Hamilton, IL 62341	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-07	Ethan M Hoffman	kellylanz1967@gmail.com	Hamilton	IL	United States	Gay Hoffman	Debra Kelley	Signed	(1) The employer does not elect the employers’ liability coverage.	Ethan M Hoffman	kellylanz1967@gmail.com	Self	Hamilton	IL	United States	Gay Hoffman	Debra Kelley	Signed
661	2021-10-01 09:00	Anonymous (not verified)	71.34.184.201	Jose Tavares	Proprietorship	1175 Office Park Rd 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.	2021-09-24	Jose Tavares	deb@piciowa.com	1175 Office Park Rd Apt 109 WDM IA 50266	Polk	Iowa	Martin Pinon	Debra Stratton	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Tavares	deb@piciowa.com	self	WDM	Polk	IA	Martin Pinon	Debra Stratton	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
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
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
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
616	2021-08-23 13:14	Anonymous (not verified)	173.25.153.19	Levon	Proprietorship	210 S 41st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-23	Levon shheba	sheebalevon@gmail.com	West des Moines IA 50265	Polk county	IA	Alina sheeba	Delon sheeba	Signed	(1) The employer does not elect the employers’ liability coverage.	Levon sheeba	sheebalevon@gmail.com	Myself	West des Moines IA 50265	Polk county	IA	Alina sheeba	Delon sheeba	Signed
417	2021-03-03 13:49	Anonymous (not verified)	173.215.42.12	Lynx Ag LLC	Limited Liability Company	510 H Ave, Churdan IA 50050	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-03	Lance Jeffrey Glendenning	lanceandabby@wccta.net	Churdan	Greene	Iowa	Shelly L. Brus	Dena M. Anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Abby Glendenning	accounting@lynxag.com	Officer	Churdan	Greene	Iowa	Shelly L. Brus	Dena M. Anderson	Signed
418	2021-03-03 13:50	Anonymous (not verified)	173.215.42.12	Lynx Ag LLC	Limited Liability Company	510 H Ave, Churdan IA 50050	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-03	Abigail Jayne Glendenning	lanceandabby@wccta.net	Churdan	Greene	Iowa	Shelly L. Brus	Dena M. Anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Lance Jeffrey Glendenning	lanceandabby@wccta.net	President	Churdan	Greene	Iowa	Shelly L. Brus	Dena M. Anderson	Signed
419	2021-03-03 13:52	Anonymous (not verified)	173.215.42.12	Lynx Ag LLC	Limited Liability Company	510 H Ave, Churdan IA 50050	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-03	Tamara Glendenning	lanceandabby@wccta.net	Davis Junction	Ogle	Illinois	Shelly L. Brus	Dena M. Anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Lance Jeffrey Glendenning	lanceandabby@wccta.net	President	Churdan	Greene	Iowa	Shelly L. Brus	Dena M. Anderson	Signed
420	2021-03-03 13:53	Anonymous (not verified)	173.215.42.12	Lynx Ag LLC	Limited Liability Company	510 H Ave, Churdan IA 50050	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-03	Terry Scott Glendenning	lanceandabby@wccta.net	Davis Junction	Ogle	Illinois	Shelly L. Brus	Dena M. Anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Lance Jeffrey Glendenning	lanceandabby@wccta.net	President	Churdan	Greene	Iowa	Shelly L. Brus	Dena M. Anderson	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
1291	2022-09-02 13:24	Anonymous (not verified)	173.20.146.6	Nicci Keck LLC	Limited Liability Company	1107 Pheasant Valley St, Iowa City, IA 52246	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-02	Nicole Keck	niccikeckllc@gmail.com	Iowa City	Iowa	United States	Evangeline Kadera	Denise Kandel	Signed	(1) The employer does not elect the employers’ liability coverage.	Nicole Keck	niccikeckllc@gmail.com	Managing Member/Owner/President	Iowa City	Johnson	Iowa	Evangeline Kadera	Denise Kandel	Signed
1292	2022-09-02 13:26	Anonymous (not verified)	173.20.146.6	Nicci Keck LLC	Limited Liability Company	1107 Pheasant Valley St, Iowa City, IA 52246	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-02	Benjamin Darbro	darbrob@gmail.com	Iowa City	Iowa	United States	Evangeline Kadera	Denise Kandel	Signed	(1) The employer does not elect the employers’ liability coverage.	Nicole Keck	niccikeckllc@gmail.com	Managing Member/Owner/President	Iowa City	Johnson	Iowa	Evangeline Kadera	Denise Kandel	Signed
576	2021-07-14 18:13	Anonymous (not verified)	69.169.10.40	J&M Excavation Inc.	Limited Liability Company	411 Pine 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.	2021-07-14	Bruce Bilyeu	jmexcavation@outlook.com	Norwalk	Warren	IA	Mike Petersen	Dennis Bilyeu	Signed	(1) The employer does not elect the employers’ liability coverage.	Bruce Bilyeu	jmexcavation@outlook.com	Owner	Norwalk	Warren	IA	Mike Petersen	Dennis Bilyeu	Signed
1916	2023-11-21 12:31	Anonymous (not verified)	94.188.205.174	DC Painting	Proprietorship	205 Astor 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.	2023-11-03	Damion Clement	gcort06@gmail.com	Des Moines	Polk	IA	Brandi Haight	Dennis Clement	Signed	(1) The employer does not elect the employers’ liability coverage.	Damion Clement	gcort06@gmail.com	Owner	205 Astor Street	Polk	IA	Brandi Haight	Dennis Clement	Signed
1133	2022-05-29 12:39	Anonymous (not verified)	75.162.116.31	Thompson Trades	Limited Liability Company	3371 200th 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.	2022-05-29	shane thompson	shane@thompsontrades.net	prole	IA	IA	Rebecca Thompson	Denyse Thompson	Signed	(1) The employer does not elect the employers’ liability coverage.	shane thompson	shane@thompsontrades.net	owner	prole	IA	IA	Rebecca Ann Thompson	Denyse Rae Thompson	Signed
1606	2023-04-26 11:42	Anonymous (not verified)	94.188.205.166	Dean Petty	Proprietorship	309 Locust Street De Soto	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Dean Robert Petty	dean.r.petty@gmail.com	De Soto	Dallas	Iowa	Sheanah Wright	Derek Mullins	Signed	(1) The employer does not elect the employers’ liability coverage.	Dean Robert Petty	dean.r.petty@gmail.com	Owner	309 Locust Street De Soto	Dallas	Iowa	Sheanah Wright	Derek Mullins	Signed
1607	2023-04-26 11:42	Anonymous (not verified)	94.188.205.166	Dean Petty	Proprietorship	309 Locust Street De Soto	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Dean Robert Petty	dean.r.petty@gmail.com	De Soto	Dallas	Iowa	Sheanah Wright	Derek Mullins	Signed	(1) The employer does not elect the employers’ liability coverage.	Dean Robert Petty	dean.r.petty@gmail.com	Owner	309 Locust Street De Soto	Dallas	Iowa	Sheanah Wright	Derek Mullins	Signed
1608	2023-04-26 11:51	Anonymous (not verified)	94.188.205.167	Jesus Lozano	Proprietorship	1334 E 16th st Des Moines Iowa 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-26	Jesus Lozano	Jesuslozano0086@icloud.com	Des Moines	Polk	Iowa	Sheanah Wright	Derek Mullins	Signed	(1) The employer does not elect the employers’ liability coverage.	Jesus Lozano	Jesuslozano0086@icloud.com	Owner	Des Moines	Polk	Iowa	Sheanah Wright	Derek Mullins	Signed
1609	2023-04-26 11:58	Anonymous (not verified)	94.188.205.168	edwin gonzalez	Proprietorship	115 e ayers st 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.	2023-04-26	edwin gonzalez	lrestrada83@gmail.com	osceola	Clark	ia	Sheanah Wright	Derek Mullins	Signed	(1) The employer does not elect the employers’ liability coverage.	edwin gonzalez	lrestrada83@gmail.com	owner	osceola	clarke	ia	Sheanah Wright	Derek Mullins	Signed
1610	2023-04-26 12:03	Anonymous (not verified)	94.188.205.175	Thomas J Mullins	Proprietorship	6569 Vista Dr. 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.	2023-04-26	Thomas J Mullins	mullinsthomasj@gmail.com	West Des Moines	Dallas	IA	Sheanah Wright	Derek Mullins	Signed	(1) The employer does not elect the employers’ liability coverage.	Thomas J Mullins	mullinsthomasj@gmail.com	Self	West Des Moines	Dallas	IA	Sheanah Wright	Derek Mullins	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
1058	2022-04-19 13:19	Anonymous (not verified)	50.83.154.192	Property Maintenance Services of Iowa LLC	Limited Liability Company	PO Box 166 Low Moor IA 52757	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-19	Frederick Stewart	curlyfry42000@yahoo.com	LOW MOOR	IA	United States	Irene R Stewart	Derek S Jensen	Signed	(1) The employer does not elect the employers’ liability coverage.	Frederick Lee Stewart	zombiesby2012@gmail.com	Owner	Clinton	IA	United States	Irene R Stewart	Derek S Jensen	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
1409	2023-01-05 11:55	Anonymous (not verified)	173.23.88.7	Top tier gutter systems llc	Limited Liability Company	405a 1st Ave sw Cedar Rapids, 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.	2023-01-05	Rocky layne smith	toptierguttersystems@yahoo.com	Cedar Rapids	Linn	IA	Faye momodu	Rocky smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Rocky smith	toptierguttersystems@yahoo.com	Self	Cedar Rapids	Linn	IA	Faye momodu	Derrick	Signed
578	2021-07-16 15:26	Anonymous (not verified)	184.80.177.137	Scotty's Appliance & TV, LLC	Limited Liability Company	529 5th St NW - 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.	2021-07-16	Sandra Krogman	jheims@english-insurance.com	Dyersville	Dubuque	Iowa	Joyce Heims	Derrick Parsons	Signed	(1) The employer does not elect the employers’ liability coverage.	Derrick Parsons	jheims@english-insurance.com	agent	Dyersville	Dubuque	Iowa	Joyce Heims	Derrick Parsons	Signed
638	2021-09-13 09:18	Anonymous (not verified)	74.84.91.178	Thomas Tremble	Proprietorship	1209 University Avenue, 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.	2021-08-09	Thomas Tremble	TJTremble21@gmail.com	Dubuque	Dubuque	Iowa	Gabe Drewelow	Derrick Parsons	Signed	(1) The employer does not elect the employers’ liability coverage.	Thomas Tremble	TJTremble21@gmail.com	self	Dubuque	Dubuque	Iowa	Gabe Drewelow	Derrick Parsons	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
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
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
1004	2022-03-23 15:01	Anonymous (not verified)	104.201.110.2	Ryan Fischer	Proprietorship	809 8th St 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.	2022-03-23	Ryan Fischer	rfischer@phillipsstaffod.com	Des Moines	Polk	IA	Josh Stafford	Desiree Dennis	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Fischer	rfischer@phillipsstafford.com	Self	DES MOINES	IA	United States	Josh Stafford	Desiree Dennis	Signed
271	2020-09-27 20:30	Anonymous (not verified)	173.17.8.56	Hutch's Parking Lot Sweeping Inc	Limited Liability Company	5235 Jennifer 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.	2020-09-27	William E Hutchinson Jr	btnwhutch@aol.com	Pleasant Hill	Polk	Iowa	Tracy Hutchinson	Diana Benda	Signed	(1) The employer does not elect the employers’ liability coverage.	William E Hutchinson Jr	btnwhutch@aol.com	Self	Pleasant Hill	Polk	Iowa	Tracy Hutchinson	Diana Benda	Signed
317	2020-11-15 19:20	Anonymous (not verified)	172.58.83.192	All Cut Lawn Care	Proprietorship	3506 Glover Ave. Des Moines Iowa 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-11-15	Michael D Money	michaelmoney883@gmail.com	Des Moines	Polk	Iowa	Deanna L Phagan	Diana J Jennings	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael D Money	michaelmoney883@gmail.com	Myself	Des Moines	Polk	Iowa	Deanna L Phagan	Diana J Jennings	Signed
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
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
295	2020-10-28 15:19	Anonymous (not verified)	72.46.55.242	SAI'S RENTALS LLC	Limited Liability Company	637 S ANKENY BLVD, 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.	2020-10-28	SUMEET SEHGAL	saisrentals.avisbudget@gmail.com	ANKENY, IA	POLK	IOWA	CLINT LILIENTHAL	DIANNE KELLE	Signed	(1) The employer does not elect the employers’ liability coverage.	SUMEET SEHGAL	saisrentals.avisbudget@gmail.com	SELF	ANKENY	POLK	IOWA	CLINT LILIENTHAL	DIANNE KELLE	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
1530	2023-03-23 16:14	Anonymous (not verified)	94.188.205.166	Los Cousins gutters	Limited Liability Company	901 sw 62nd st 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.	2023-03-23	Freddy Morales	1981ayoria@gmail.com	Des Moines Ia	Polk	Iowa	Denni bazan	Dionicio morales	Signed	(1) The employer does not elect the employers’ liability coverage.	Freddy Morales	1981ayoria@gmail.com	1981ayoria@gmail.com	Desmoines	Polk	Ia	Dennis Bazan	Dionicio Morales	Signed
500	2021-04-29 13:09	Anonymous (not verified)	204.155.61.217	JWJ Home Remodeling LLC	Limited Liability Company	16915 Weaver Lake Dr, Maple Grove MN 55311	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-29	Jackson Janzen	jacksonjanzen@hailmayday.com	Maple Grove	hennepin	MN	Ashley Kraft	DocuSign	Signed	(1) The employer does not elect the employers’ liability coverage.	Jackson Janzen	jacksonjanzen@hailmayday.com	Owner	Maple Grove	Hennepin	MN	Ashley Kraft	DocuSign	Signed
305	2020-11-02 08:40	Anonymous (not verified)	204.124.192.31	JPS Framing	Proprietorship	102 WALL 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.	2020-11-02	JACKELYN SANCHEZ	JPSFRAMING629@GMAIL.COM	DES MOINES	POLK	IOWA	ROGELIO SANCHEZ	DOMINIQUE SANCHEZ	Signed	(1) The employer does not elect the employers’ liability coverage.	JUAN SERRANO	JPSFRAMING629@GMAIL.COM	EMPLOYER	DES MOINES	POLK	IOWA	ROGELIO SANCHEZ	DOMINIQUE SANCHEZ	Signed
193	2020-06-24 11:13	Anonymous (not verified)	173.28.196.82	Gray Nation LLC DBA Gray Goat Tattoo	Limited Liability Company	116 N 1st Street West Branch, Iowa 52358-9663	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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.	2020-06-24	Elizabeth Gray	beth.gray516@gmail.com	West Branch	Cedar	Iowa	Luis Ordenana	Don Naugthon	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Elizabeth Gray	beth.gray516@gmail.com	LLC Member	West Branch	Cedar	Iowa	Luis Ordenana	Don Naughton	Signed
1014	2022-03-28 16:33	Anonymous (not verified)	76.102.203.170	Self - Maryssa Wanlass	Proprietorship	871 Wood St. Oakland CA 94607	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-01	Maryssa Wanlass	maryssa.wanlass@alli-center.com	Oakland	Alameda	California	Mark Vashro	Don Naughton	Signed	(1) The employer does not elect the employers’ liability coverage.	Maryssa Wanlass	maryssa.wanlass@alli-center.com	Self	Oakland	Alameda	California	Mark Vashro	Don Naughton	Signed
226	2020-08-07 11:37	Anonymous (not verified)	71.39.227.238	Clinton Luellen	Proprietorship	18591 N Ave, Minburn, IA 50167	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-07	Clinton Luellen	CALuellen@gmail.com	Minburn	Dallas	Iowa	Winette Luellen	Don Richardson	Signed	(1) The employer does not elect the employers’ liability coverage.	Clinton Luellen	CALuellen@gmail.com	Self	Minburn	Dallas	Iowa	Winette Luellen	Don Richardson	Signed
1327	2022-10-06 12:23	Anonymous (not verified)	71.39.227.238	RICK OBEREMBT	Proprietorship	1702 SYCAMORE ST, DALLAS CNETER, 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.	2022-10-05	RICK OBEREMBT	werock83@gmail.com	DALLAS CENTER	DALLAS	IOWA	ABBEY LUELLEN	DON RICHARDSON	Signed	(1) The employer does not elect the employers’ liability coverage.	RICK OBEREMBT	werock83@gmail.com	SELF	DALLAS CENTER	DALLAS	IOWA	ABBEY LUELLEN	DON RICHARDSON	Signed
1335	2022-10-17 11:32	Anonymous (not verified)	71.39.227.238	PELZER AG LLC	Limited Liability Company	16864 280TH ST, 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.	2022-10-17	MATT PELZER	MPELZERFARMS@GMAIL.COM	REDFIELD	DALLAS	IOWA	ABBEY LUELLEN	DON RICHARDSON	Signed	(1) The employer does not elect the employers’ liability coverage.	MATT PELZER	MPELZERFARMS@GMAIL.COM	PRESIDENT	REDFIELD	DALLAS	IOWA	ABBEY LUELLEN	DON RICHARDSON	Signed
949	2022-03-04 16:09	Anonymous (not verified)	173.20.147.171	Duwa Waterproofing LLC	Limited Liability Company	729 Deer view Ave, Tiffin, IA 52340	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Stacy Duwa	duwawaterproofing@gmail.com	Tiffin	Johnson	Iowa	Lauren Obermann	Don Vittetoe	Signed	(1) The employer does not elect the employers’ liability coverage.	Stacy Duwa	duwawaterproofing@gmail.com	owner	Tiffin	Johnson	Iowa	Lauren Obermann	Don Vittetoe	Signed
39	2020-01-19 11:00	Anonymous (not verified)	75.163.84.145	Allen L Bryen	Proprietorship	2609 Madison St Bellevue NE 68005	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-19	Allen Lee Bryen	Allen.Bryen@yahoo.com	Bellevue	Sarpy	Nebraska	Jeffrey Coats	Donald Coats	Signed	(1) The employer does not elect the employers’ liability coverage.	Allen L Bryen	Allen.Bryen@yahoo.com	Self	Bellevue	Sarpy	Nebraska	jeffrey Coats	Donald Coats	Signed
1085	2022-05-03 10:38	Anonymous (not verified)	65.144.174.26	Caleb Schroeder	Proprietorship	4051 SW 56th St Des Moines, IA 50321	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-03	Caleb Schroeder	calebpschroeder@gmail.com	Des Moines	Polk	Iowa	Michele Schroeder	Donald Schroeder	Signed	(1) The employer does not elect the employers’ liability coverage.	Caleb Schroeder	calebpschroeder@gmail.com	Self	Des Moines	Polk	Iowa	Michele Schroeder	Donald Schroeder	Signed
126	2020-04-21 21:19	Anonymous (not verified)	69.76.135.87	Merge Midwest Engineering, LLC	Limited Liability Company	2668 W. Catalpa Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-21	Mark Daniel Stuempel	mstuempel@mergemidwest.com	Kansas City	Wyandotte	KANSAS	Anna Langer	Donna Stuempel	Signed	(1) The employer does not elect the employers’ liability coverage.	Janelle Clayton	jclayton@mergemidwest.com	LLC Member	Olathe	Johnson	KS	Anna Langer	Donna Stuempel	Signed
1053	2022-04-14 21:08	Anonymous (not verified)	50.83.192.136	John E Snyder JR	Proprietorship	1677 PACIFIC ST, MURRAY, IA 50174	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-14	John Snyder JR	jrsweldingia@gmail.com	MURRAY	Clarke	Iowa	Shelly Goslar	Dorene Short	Signed	(1) The employer does not elect the employers’ liability coverage.	John Snyder JR	jrsweldingia@gmail.com	Selg	MURRAY	Clarke	Iowa	Shelly Goslar	Dorene Short	Signed
843	2022-01-20 07:48	Anonymous (not verified)	207.199.230.75	Heart of Iowa Inspections LLC	Limited Liability Company	2700 Highway 63 Oskaloosa, Iowa 52577	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-20	Randy DeHeer	rdenheer2828@gmail.com	Oskaloosa	Mahaska	Iowa	Cheryl Brown	Doris Crile	Signed	(1) The employer does not elect the employers’ liability coverage.	Randy DeHeer	rdenheer2828@gmail.com	self	Oskaloosa	Mahaska	Iowa	Cheryl Brown	Doris Crile	Signed
934	2022-02-23 12:13	Anonymous (not verified)	207.199.230.75	Randy DeHeer	Limited Liability Company	2700 Highway 63 Oskaloosa, Iowa 52577	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-23	Randy DeHeer	rdeheer2828@gmail.com	Oskaloosa	Mahaska	Jowa	Cheryl Brown	Doris Crile	Signed	(1) The employer does not elect the employers’ liability coverage.	Randy DeHeer	rdeheer2828@gmail.com	Self	Oskaloosa	Mahaska	Iowa	Cheryl Brown	Doris Crile	Signed
932	2022-02-22 17:20	Anonymous (not verified)	72.212.49.250	Duane Bruxvoort	Proprietorship	201 Park Lane, 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.	2021-01-01	Duane L Bruxvoort	duanebrux@gmail.com	Pella	Marion	Iowa	Megan Lee Pingel	Dorothy Jean Bruxvoort	Signed	(1) The employer does not elect the employers’ liability coverage.	Duane Bruxvoort	duanebrux@gmail.com	Self	Pella	Marion	Iowa	Megan Lee Pingel	Dorothy Bruxvoort	Signed
2111	2024-03-21 14:28	Anonymous (not verified)	94.188.205.168	James Watson	Limited Liability Company	4708 71st Street Urbandale, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-24	James Edward watson	junior99@email.com	Urbandale	IA	United States	Susie Givant	Doug Frame	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Lantz	jason@lantzelite.com	Employer	Urbandale	IA	United States	Susie Givant	Doug Frame	Signed
1215	2022-07-20 13:43	Anonymous (not verified)	173.21.133.45	Ottumwa mow & snow LLC	Limited Liability Company	11443 Bladensburg Rd. Ottumwa IA 52501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-20	Lucia A Hughes	lucyh68313@gmail.com	Ottumwa	Wapello	Iowa	Katy Knott	Doug Knott	Signed	(1) The employer does not elect the employers’ liability coverage.	RJ Hallman	rjhallman@fedins.com	Insurance	Owatonna	Steele	Minnesota	Katy Knott	Doug Knott	Signed
1220	2022-07-21 13:12	Anonymous (not verified)	172.58.83.160	Ottumwa mow & snow LLC	Limited Liability Company	11443 Bladensburg Rd. Ottumwa IA 52501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	María Duarte	mariacabrera515@icloud.com	Ottumwa	Wapello	Iowa	Katy Knott	Doug Knott	Signed	(1) The employer does not elect the employers’ liability coverage.	RJ Hallman	rjhallman@fedins.com	Insurance	Owatonna	Steele	Minnesota	Katy Knott	Doug Knott	Signed
1225	2022-07-23 18:01	Anonymous (not verified)	174.242.224.34	Ottumwa mow & snow llc	Limited Liability Company	11443 Bladensburg Rd Ottumwa IA 52501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-23	JoAnn laBella	joannlabella@gmail.com	Ottumwa	Wapello	IA	Doug Knott	Katy Knott	Signed	(1) The employer does not elect the employers’ liability coverage.	RJ Hallman	rjhallman@fedins.com	Insurance	Owatonna	Steele	MN	Katy knott	Doug knott	Signed
1226	2022-07-23 18:02	Anonymous (not verified)	174.242.224.34	Ottumwa mow & snow llc	Limited Liability Company	11443 Bladensburg Rd Ottumwa IA 52501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-23	JoAnn laBella	joannlabella@gmail.com	Ottumwa	Wapello	IA	Doug Knott	Katy Knott	Signed	(1) The employer does not elect the employers’ liability coverage.	RJ Hallman	rjhallman@fedins.com	Insurance	Owatonna	Steele	MN	Katy knott	Doug knott	Signed
752	2021-11-17 08:22	Anonymous (not verified)	166.181.82.81	Michael sprout	Limited Liability Company	1208 N THORNWOOD AVE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-14	Michael Sprout	1293newhome@gmail.com	Davenport	IA	IA	Mike smith	Doug palmer	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Sprout	1293newhome@gmail.com	Geico	Davenport	IA	IA	Mike smith	Doug palmer	Signed
511	2021-05-10 17:53	Anonymous (not verified)	173.24.231.27	QSC Snow Removal	Proprietorship	1211 Carroll Boone 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.	2021-05-10	Vincent A Kaylor	phenox32@gmail.com	Boone	IA	United States	Lori Harvey	Doug Robertson	Signed	(1) The employer does not elect the employers’ liability coverage.	Vincent A Kaylor	phenox32@gmail.com	self	Boone	IA	United States	Lori Harvey	Doug Robertson	Signed
1799	2023-08-14 14:42	Anonymous (not verified)	94.188.205.174	Magiclean	Proprietorship	2001 S. 16th Burlington Iowa 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.	2023-08-14	Sydney Bornsheuer	Mistycale@gmail.com	Burlington	Iowa	Iowa	Dustina Fenton	Doug Shupick	Signed	(1) The employer does not elect the employers’ liability coverage.	Misty Cale	magicleanburlington@gmail.com	Owner	Burlington	Des Moines	Iowa	Dustina Fenton	Doug Shupick	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
948	2022-03-04 13:23	Anonymous (not verified)	71.28.216.129	Zack & Rachael Bushman	Proprietorship	321 Countryside Dr, Waukon, IA 52172	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Rachael Bushman	rachaelnessa@yahoo.com	Waukon	Allamakee	IA	Zack Bushman	Doyle Wegner	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Zack Bushman	rachaelnessa@yahoo.com	Owner Operator	Waukon	Allamakee	IA	Rachael Bushman	Doyle Wegner	Signed
2089	2024-03-12 10:58	Anonymous (not verified)	94.188.205.166	Margarito R Guzman	Proprietorship	4512 S 22nd ST 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.	2024-03-12	Margarito R Guzman	abrahamguzman030@gmail.com	omaha	douglas	NE	jose abraham guzman garcia	Drakkar Rapaich	Signed	(1) The employer does not elect the employers’ liability coverage.	Margarito Guzman	abrahamguzman030@gmail.com	Owner	Omaha	Douglas	Nebraksa	jose abraham guzman garcia	Drakkar Rapaich	Signed
821	2022-01-04 10:06	Anonymous (not verified)	173.18.4.60	Levi Walker	Proprietorship	601 N 10th Avenue Winterset, Iowa 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.	2022-01-04	Levi Walker	walker.lw31@gmail.com	Winterset	Madison	Iowa	Morgan Walker	Drew Van Laar	Signed	(1) The employer does not elect the employers’ liability coverage.	Levi Walker	walker.lw31@gmail.com	self	Winterset	Madison	Iowa	Morgan Walker	Drew Van Laar	Signed
646	2021-09-20 08:54	Anonymous (not verified)	173.24.107.209	QCA Professional Contractors	Limited Liability Company	3314 67th Ave, Moline, IL. 61265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-20	Allan Celada	allancelada@qcaprocontractors.com	Moline	Rock Island	IL	Alexander Celada	Drexel Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Allan Celada	allancelada@qcaprocontractors.com	self	Moline	Rock Island	IL	Alexander Celada	Drexel Miller	Signed
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
592	2021-07-29 16:44	Anonymous (not verified)	138.43.237.95	Choice Ag Services INC	Proprietorship	1841 Firefly Rd, Manchester, IA 52057	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-29	Adam Reth	adam@choiceagservices.com	Manchester	IA	United States	Josh Soppe	Adam Reth	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Reth	adam@choiceagservices.com	Owner	Manchester	Delaware	Iowa	Josh Soppe	Dustin Fessler	Signed
1622	2023-05-01 16:05	Anonymous (not verified)	94.188.205.174	Danny Shineflew	Proprietorship	103th 10street West Des Moines	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-01	Danny Shineflew	dannyshineflew@gmail.com	West Des Moines	Polk	Iowa	Tony Ekman	Dustin Hogan	Signed	(1) The employer does not elect the employers’ liability coverage.	Danny Shineflew	dannyshineflew@gmail.com	self	West Des Moines	Polk	Iowa	Tony Ekman	Dustin Hogan	Signed
1207	2022-07-15 10:02	Anonymous (not verified)	75.89.78.50	A&J Remodeling LLC	Limited Liability Company	2 Bungalow Ct Newton, Iowa 50208	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-15	Austin Hudson	ahudson7536@gmail.com	Newton	Jasper	IA	Liz Allen	Dustin Ingram	Signed	(1) The employer does not elect the employers’ liability coverage.	Austin Hudson	anjremodel@gmail.com	Co-owner	Newton	Jasper	IA	Liz Allen	Dustin Ingram	Signed
626	2021-08-31 11:39	Anonymous (not verified)	166.181.81.253	Birds landscape maintenance LLC	Limited Liability Company	1307 w 4th st south	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-31	Michael Alan bird	birdslawn@hotmail.com	Newton	Jasper	Iowa	Jeff Dennis carder	Dustin James bos	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Alan bird	birdslawn@hotmail.com	Same - owner	Newton	Jasper	Iowa	Jeff Dennis carder	Dustin James bos	Signed
709	2021-11-04 12:38	Anonymous (not verified)	50.83.182.182	All Pro Painting LLC	Limited Liability Company	5431 Gear Street Prole 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.	2020-11-04	Tory Webb (United Trades Group LLC)	toryw@unitedtradesgroup.org	Norwalk	Warren	Iowa	Ryan Drabek	Dustin Kohler	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Adams	adam@allpropaintingdsm.com	Project Manager	Prole	Warren	Iowa	Ryan Drabek	Dustin Kohler	Signed
710	2021-11-04 12:57	Anonymous (not verified)	50.83.182.182	United Trades Group LLC	Limited Liability Company	4813 Candlewick Drive 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.	2020-11-04	Tory Webb	torywebbdmi@gmail.com	Norwalk	Polk	Iowa	Ryan Drabek	Dustin Kohler	Signed	(1) The employer does not elect the employers’ liability coverage.	Tory Webb	toryw@unitedtradesgroup.org	Owner, Management	Norwalk	Iowa	United States	Ryan Drabek	Dustin Kohler	Signed
732	2021-11-09 15:25	Anonymous (not verified)	50.83.182.182	United Trades Group LLC	Limited Liability Company	4813 Candlewick 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.	2021-11-09	Ryan Drabek	ryand@unitedtradesgroup.org	Des Moines	Polk	Iowa	Dustin Kohler	Trevor Spidle	Signed	(1) The employer does not elect the employers’ liability coverage.	Tory Webb	toryw@unitedtradesgroup.org	Owner, Management	Norwalk	Warren	Iowa	Trevor Spidle	Dustin Kohler	Signed
273	2020-10-05 13:57	Anonymous (not verified)	173.30.54.139	Jackson Exteriors	Proprietorship	705 Cherry Avenue Woodward,ia 50276	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-05	Lucas Jackson	ljajackson41977@gmail.com	Woodward	IA	United States	Cody Roth	Dustin Perry	Signed	(1) The employer does not elect the employers’ liability coverage.	Lucas Jackson	ljajackson41977@gmail.com	Owner	Woodward	Dallas	United States	Cody Roth	Dustin perry	Signed
127	2020-04-24 09:18	Anonymous (not verified)	63.152.82.5	TD Auto Services LLC	Limited Liability Company	451 W Parker St Waterloo IA 50703	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-27	Dakoda Sellers	dakoda.d.sellers@gmail.com	Waverly	Bremer	IA	Jennie Roster	Dustin Roster	Signed	(1) The employer does not elect the employers’ liability coverage.	Dakoda D Sellers	dakoda.d.sellers@gmail.com	Owner	Waverly	Bremer	IA	Jennie Roster	Dustin Roster	Signed
1299	2022-09-07 14:55	Anonymous (not verified)	167.142.60.66	Harleen Trenching	Proprietorship	2066 X Ave, Madrid Iowa 50156	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-07	Bill Harleen	sandyharleen@hotmail.com	Madrid	Boone	Iowa	Thomas H Andersen	Dustin T Andersen	Signed	(1) The employer does not elect the employers’ liability coverage.	Bill Harleen	Harleentrenching@hotmail.com	Self	Madrid	Boone	Iowa	Thomas H Andersen	Dustin T Andersen	Signed
533	2021-06-03 20:37	Anonymous (not verified)	75.162.171.128	KP Repair LLC	Limited Liability Company	719 10th St. NE Mason City, Iowa.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-06-03	Alexander Wessels	kprepair@outlook.com	MASON CITY	Cerro Gordo	IA	Sadie Lonning	Dusty Howe	Signed	(1) The employer does not elect the employers’ liability coverage.	Alexander Wessels	kprepair@outlook.com	Owner	MASON CITY	Cerro Gordo	IA	Sadie Lonning	Dusty Howe	Signed
64	2020-02-18 10:02	Anonymous (not verified)	198.167.182.164	Elite Electrical Service LLC	Limited Liability Company	2035 Lynncrest Dr, 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.	2020-02-18	Sean Brogan	brogan_sean@hotmail.com	Coralville	Johnson	Iowa	Kyle Stahle	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Sean Brogan	brogan_sean@hotmail.com	Managing Member	Coralville	Johnson	Iowa	Kyle Stahle	Dyan Kriener	Signed
67	2020-02-19 10:16	Anonymous (not verified)	198.167.182.164	AWF579 LLC	Limited Liability Company	13 Lynden Dr NE, Iowa City, IA 52240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-18	Jeffrey Schiltz	jeffschiltz2@yahoo.com	Iowa City	Johnson	Iowa	Kyle Stahle	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeffrey Schiltz	jeffschiltz2@yahoo.com	Managing Member	Iowa City	Johnson	Iowa	Kyle Stahle	Dyan Kriener	Signed
85	2020-03-09 08:17	Anonymous (not verified)	198.167.182.164	Simply Anchored LLC dba Simply Mae's	Limited Liability Company	601 Broad St, Story City, IA 50248	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-05	Jessi Kettenacker	jessi@simplymaes.com	Story City	Story	Iowa	Lynn McKinney	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Jessi Kettenacker	jessi@simplymaes.com	Managing Member	Story City	Story	Iowa	Lynn McKinney	Dyan Kriener	Signed
86	2020-03-09 08:19	Anonymous (not verified)	198.167.182.164	Simply Anchored LLC dba Simply Mae's	Limited Liability Company	601 Broad St, Story City, IA 50248	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-05	Cande Coulter	cande@simplymaes.com	Story City	Story	Iowa	Lynn McKinney	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Candy Coulter	cande@simplymaes.com	Managing Member	Story City	Story	Iowa	Lynn McKinney	Dyan Kriener	Signed
151	2020-05-07 15:57	Anonymous (not verified)	198.167.182.164	Hawk-I Trucking LLC	Limited Liability Company	521 Greenfield Dr, Tiffin, IA 52340	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-06	Chad Lee Freeman	ricenogle@southslope.net	Tiffin	Johnson	IA	Scott Freeman	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Chad Lee Freeman	ricenogle@southslope.net	Managing Member	Tiffin	Johnson	IA	Scott Freeman	Dyan Kriener	Signed
152	2020-05-11 15:56	Anonymous (not verified)	198.167.182.164	Hawk-I Trucking LLC	Limited Liability Company	521 Greenfield Dr, Tiffin, IA 52340	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-11	Tyler Rogers	tylerrogersinc@yahoo.com	Iowa City	Johnson	Iowa	Scott Freeman	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Tyler Rogers	tylerrogersinc@yahoo.com	Member	Iowa City	Johnson	Iowa	Scott Freeman	Dyan Kriener	Signed
438	2021-03-17 06:52	Anonymous (not verified)	198.167.182.164	David L Ridnour	Proprietorship	1415 4th St, 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.	2021-03-16	David L Ridnour	dlridnour@gmail.com	Perry	Dallas	Iowa	Steve Fishman	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	David L Ridnour	dlridnour@gmail.com	Owner	Perry	Dallas	Iowa	Steve Fishman	Dyan Kriener	Signed
488	2021-04-20 13:42	Anonymous (not verified)	69.63.16.2	STC Construction LLC	Limited Liability Company	329 Sycamore 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.	2021-04-20	Sean Crane	stc0241@gmail.com	Riverside	Washington	Iowa	Carol Glass	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Sean Crane	stc0241@gmail.com	Managing Member	Riverside	Washingon	Iowa	Carol Glass	Dyan Kriener	Signed
489	2021-04-20 13:47	Anonymous (not verified)	69.63.16.2	Mow-n-Mor Lawn & Landscaping LLC	Limited Liability Company	2585 500th St SW, Kalona, IA 52247	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-19	Robert Sieren	mtesdell@yahoo.com	Kalona	Johnson	Iowa	Scott Freeman	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Sieren	mtesdell@yahoo.com	Managing Member	Kalona	Johnson	Iowa	Scott Freeman	Dyan Kriener	Signed
505	2021-05-10 07:06	Anonymous (not verified)	69.63.16.2	Three Boys Contracting LLC	Limited Liability Company	1108 Cullen Dr, Tiffin, IA 52340	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-08	Brandon J Campbell	threeboyscarpentry@gmail.com	Tiffin	Johnson	Iowa	Steve Fishman	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandon J Campbell	threeboyscarpentry@gmail.com	Managing Member	Tiffin	Johnson	Iowa	Steve Fishman	Dyan Kriener	Signed
856	2022-01-26 13:44	Anonymous (not verified)	69.63.16.2	Rick Peterson	Proprietorship	3366 Lynden Heights Rd NE, Iowa City IA 52240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-26	Richard Peterson	insurancecommercialsam@greenstate.org	Iowa City	Johnson	Iowa	Jonathan Gonzalez	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Peterson	insurancecommercialsam@greenstate.org	Owner	Iowa City	Johnson	IA	Jonathan Gonzalez	Dyan Kriener	Signed
860	2022-01-27 11:31	Anonymous (not verified)	69.63.16.2	Dreams 2 Reality Construction LLC	Limited Liability Company	17615 Meredith 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.	2022-01-26	Rob Rubsam	rob@dreams2reality.us	Waukee	Dallas	Iowa	Kyle Stahle	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Rob Rubsam	rob@dreams2reality.us	Member	Waukee	Dallas	Iowa	Kyle Stahle	Dyan Kriener	Signed
861	2022-01-27 11:33	Anonymous (not verified)	69.63.16.2	Dreams 2 Reality Construction LLC	Limited Liability Company	17615 Meredith 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.	2022-01-26	Lisa Rubsam	lisa@dreams2reality.us	Waukee	Dallas	Iowa	Kyle Stahle	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Lisa Rubsam	lisa@dreams2reality.us	Member	Waukee	Dallas	Iowa	Kyle Stahle	Dyan Kriener	Signed
1153	2022-06-13 16:22	Anonymous (not verified)	216.9.166.5	Ronald B Blakley	Proprietorship	2001 St Bridgets Rd NE, Solon IA 52333	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-08	Ronald B Blakley	sanjahunt@gmail.com	Solon	Johnson	Iowa	Scott G Freeman	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Ronald B Blakley	Sanjahunt@gmail.com	Owner	Solon	Johnson	Iowa	Scott G Freeman	Dyan Kriener	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
819	2022-01-02 11:39	Anonymous (not verified)	184.94.130.66	derek verhelst trucking inc	Proprietorship	1579 270th avenue canby mn 56220	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-02	derek verhelst	derekvtinc@gmail.com	canby	yellow medicine	mn	lois verhelst	dylan nelson	Signed	(1) The employer does not elect the employers’ liability coverage.	derek verhelst	derekvtinc@gmail.com	owner	canby	yellow medicine	mn	lois verhelst	dylan nelson	Signed
57	2020-02-10 15:33	Anonymous (not verified)	198.167.182.164	AllEnhancements LLC	Limited Liability Company	1122 Woodland Ln, LeClaire, IA 52753	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-31	Brett Allen	allenhancementsllc@outlook.com	LeClaire	Scott	Iowa	Steven J Fishman	E Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Brett Allen	allenhancementsllc@outlook.com	Managing Member	LeClaire	Scott	Iowa	Steven J Fishman	E Dyan Kriener	Signed
59	2020-02-11 11:34	Anonymous (not verified)	198.167.182.164	Besch Electric LLC	Limited Liability Company	317 Sycamore 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.	2020-02-03	Daniel Besch	beschd@hotmail.com	Riverside	Washington	Iowa	Steven J Fishman	E Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Besch	beschd@hotmail.com	Managing Member	Riverside	Washington	Iowa	Steven J Fishman	E Dyan Kriener	Signed
60	2020-02-12 10:10	Anonymous (not verified)	198.167.182.164	Sara Torres	Proprietorship	419 Lilac St, Tiffin, IA 52340	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-11	Sara Torres	skb_blue08@hotmail.com	Tiffin	Johnson	Iowa	Steven J Fishman	E. Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Sara Torres	skb_blue08@hotmail.com	Owner	Tiffin	Johnson	Iowa	Steven J Fishman	E Dyan Kriener	Signed
1150	2022-06-10 16:14	Anonymous (not verified)	173.29.125.38	Vernon Tim McClain	Limited Liability Company	2717 Thompson 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.	2022-06-10	Vernon Tim McClain	mcclainlawn@gmail.com	Des Moines	POlk	Iowa	Ilisha Carter	Earl Warren Jr.	Signed	(1) The employer does not elect the employers’ liability coverage.	vernon mcclain	mcclainlawn@gmail.com	business owner	des moines	polk	iowa	Ilisha Carter	Earl Warren Jr.	Signed
1459	2023-02-16 09:07	Anonymous (not verified)	94.188.205.166	Lakerats	Limited Liability Company	112 W Court Winterset IA 50273	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-05	Kyra Moore	kyra@novushomemortgage.com	Urbandale	Polk	Iowa	Jessica Anderson	Easton Anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Kyra Moore	kyra@novushomemortgage.com	Owner	Urbandale	Polk	Iowa	Jessica Anderson	Easton Anderson	Signed
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
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
334	2020-12-07 12:38	Anonymous (not verified)	173.19.190.160	Broadband Installations of Iowa LLC	Limited Liability Company	P.O. Box 728 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.	2020-12-07	Charles Wood	cwood.bband@outlook.com	CEDAR RAPIDS	IA	IA	Eva Wood	Tamara Wood	Signed	(1) The employer does not elect the employers’ liability coverage.	Skyla Siech	skylabbi@outlook.com	Offcie Manager	Ely	Linn	Iowa	Melvin Harter	Eddie Bell	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
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
778	2021-12-05 11:39	Anonymous (not verified)	71.34.165.66	Perfection heating and Plumbing LLC	Limited Liability Company	2522 3 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.	2021-12-05	Edward William cooper	ecooper@amermech.com	Altoona	Polk	IA	Lindsay cooper	Edward cooper SR	Signed	(1) The employer does not elect the employers’ liability coverage.	Eddie Cooper	ecooper@amermech.com	Self	Altoona	Polk	IA	Lindsay cooper	Edward cooper SR	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
1995	2024-01-23 15:08	Anonymous (not verified)	94.188.205.167	Spencer Abbott	Proprietorship	1358 170th Ave, Murray Iowa 50174	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Spencer Abbott	sabbott1800@gmail.com	Murray	Clarke	Iowa	Juanita Yutzy	Elaine Lee	Signed	(1) The employer does not elect the employers’ liability coverage.	Spencer Abbott	sabbott1800@gmail.com	sole proprietor	Murray	Clarke	Iowa	Juanita Yutzy	Elaine Lee	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
858	2022-01-27 08:06	Anonymous (not verified)	75.162.81.119	MR Custom Tile & Flooring LLC	Limited Liability Company	14390 Newbold 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.	2022-01-27	Matthew Royer	royer20@yahoo.com	Indianola	Warren	United States	Leiloni Royer	Elena Royer	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Royer	royer20@yahoo.com	Myself	Indianola	Warren	United States	Leiloni Royer	Elena Royer	Signed
1084	2022-05-02 15:23	Anonymous (not verified)	173.23.196.11	Sweet Green Arborist Services, LLC	Limited Liability Company	804 W. Briggs Ave, Fairfield, IA 52556	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-02	Andrew Forest Nash	sweetgreenarborist@gmail.com	Fairfield	Jeffereson	Iowa	Eli Morgan	Rachel Morgan	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Nash	anash66@gmail.com	same	Fairfield	Jeffereson	Iowa	Rachel Morgan	Eli Morgan	Signed
1067	2022-04-23 11:17	Anonymous (not verified)	166.181.82.231	Black Squirrel Siding LLC.	Limited Liability Partnership	1512 north 1st ave 203s	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-23	Robby Bartosh	zodzoey19@gmail.com	Cedar Rapids	IA	United States	Phoenix Bartosh	Elijah Irish	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeremiah Petsche	Blacksquirrelsiding@gmail.com	business partner	coralville	johnson	iowa	Phoenix Bartosh	Elijah Irish	Signed
958	2022-03-08 20:17	Anonymous (not verified)	50.82.39.158	Ramos Drywall	Limited Liability Company	1355 Ozark Ridge, Coralville, IA 52241	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-03-08	Carlos Rene Ramos Martinez	carlosramos2345@gmail.com	Coralville	Iowa	United States	Breanna Barragan	Eliseo Tapia JR.	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Carlos Rene Ramos Martinez	carlosramos2345@gmail.com	N/A- Same Person	Coralville	Johnson County	IA	Breanna Barragan	Eliseo Tapia JR.	Signed
260	2020-09-17 10:52	Anonymous (not verified)	50.80.218.18	Decanus Property Management	Proprietorship	102 E 2nd St, Davenport IA 52801	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-17	Shonna Suzanne Dean	decanus@yahoo.com	Moline	Rock Island	Illinois	Justin E Proctor	Elizabeth A Oney	Signed	(1) The employer does not elect the employers’ liability coverage.	Shonna S Dean	decanus@yahoo.com	Self	Moline	Rock Island	Illinois	Justin E Proctor	Elizabeth A Oney	Signed
1556	2023-04-05 14:08	Anonymous (not verified)	94.188.205.169	Capstone Staffing Solutions 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.	(1) I am not electing the employers’ liability coverage.	2023-04-05	Peterson Munyasia	pete@capstonestaffingsolutions.com	Allen	USA	TX	Daniel Mwangi	Elizabeth Munene	Signed	(1) The employer does not elect the employers’ liability coverage.	Peterson Munyasia	pete@capstonestaffingsolutions.com	Owner	Allen	USA	TX	Daniel Mwangi	Elizabeth Munene	Signed
508	2021-05-10 11:56	Anonymous (not verified)	172.58.83.106	Aldo Monroy	Limited Liability Company	201 Ne 44th St , Apt 111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-10	Aldo Monroy	Aldogmonroy@gmail.com	Ankeny	Polk	IOWA	Aldo Monroy	Elizabeth lopez	Signed	(1) The employer does not elect the employers’ liability coverage.	Aldo Monroy	Aldogmonroy@gmail.com	Owner	Ankeny	Polk	IOWA	Aldo g monroy reyes	Elizabeth tavarez lopez	Signed
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
269	2020-09-23 09:18	Anonymous (not verified)	76.76.239.60	belilove company of Iowa Inc	Limited Liability Company	601 south 23rd street Fairfield Iowa 52556	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-20	James Belilove	jimb@cec-waterjet.com	Fairfield	Jefferson	Iowa	James thompson	ellen bowen	Signed	(1) The employer does not elect the employers’ liability coverage.	James Belilove	jimb@cec-waterjet.com	Owner and president	Fairfield	Jefferson	Iowa	James Thompson	Ellen Bowen	Signed
1700	2023-06-22 14:53	Anonymous (not verified)	94.188.205.166	James Trotter	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	Self	Carter Lake	Pottawattamie	IA	Shelby Schultz	Elora Trotter	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
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
1101	2022-05-13 12:55	Anonymous (not verified)	174.199.102.54	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.	2022-05-13	Daniel Blanco	chindan77@yahoo.com	Ft Dodge	Webster	IA	Vanessa Blanco	Elva Castañeda	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Blanco	chindan77@yahoo.com	Self	Ft Dodge	Webster	IA	Vanessa Blanco	Elva Castañeda	Signed
1989	2024-01-16 17:13	Anonymous (not verified)	94.188.205.168	Xcel Electric LLC	Limited Liability Company	1142 Columbus Dr Waterloo 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.	2024-01-16	Haris Mumic	h.mumic@hotmail.com	Waterloo	Black Hawk	IA	Minea Skrgic-Mumic	Elvis Mumic	Signed	(1) The employer does not elect the employers’ liability coverage.	Haris Mumic	h.mumic@hotmail.com	Owner/Employer	waterloo	Black Hawk	IA	Minea Skrgic-Mumic	Elvis Mumic	Signed
232	2020-08-16 11:28	Anonymous (not verified)	173.27.57.39	Landeros & Sons Construction, Inc	Limited Liability Partnership	1636 19th 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.	2020-08-16	Fernando Landeros	fland1983@gmail.com	Moline	Rock Island	Illinois	Adrian Landeros	Emanuel Landeros	Signed	(1) The employer does not elect the employers’ liability coverage.	Emanuel Landeros	fland1983@gmail.com	Brother	Moline	Rock Island	Illinois	Adrian Landeros	Emanuel Landeros	Signed
1315	2022-09-20 13:11	Anonymous (not verified)	173.17.128.203	Leaffilter	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.	2022-09-20	Johnny Coker	johnnycoker36@gmail.com	Altoona	Polk	Iowa	Travis Klapproth	Emilie Klapproth	Signed	(1) The employer does not elect the employers’ liability coverage.	LeafFilter	support@leafhome.com	Sub contractor	Grimes	Polk	Iowa	Travis Klapproth	Emilie Klapproth	Signed
938	2022-02-25 15:21	Anonymous (not verified)	174.215.247.215	Maria castillo	Limited Liability Company	2200 scott blvd #90 iowa city iowa 52240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-25	Maria evangelina castillo moreno	mariacastillo852@yahoo.com	Iowa city	Jonhson	Iowa	Maria castillo	Emilio Castillo	Signed	(1) The employer does not elect the employers’ liability coverage.	Maria evangelina castillo moreno	mariacastillo852@yahoo.vom	Work	Iowa city	Johnson	Iowa	Maria castillo	Emilio Castillo	Signed
1293	2022-09-03 08:03	Anonymous (not verified)	50.82.244.98	MTZ Drywall	Proprietorship	1101 Eighth 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.	2022-09-02	Richar Martinez	menace_42@icloud.com	West Des Moines	United States	Iowa	Alejandro Gonzalez	Emilio Martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Jerry Jenkins	jjenkins@farmersagent.com	N/A	Urbandale	United States	Iowa	Alejandro Gonzalez	Emilio Martinez	Signed
143	2020-04-29 09:59	Anonymous (not verified)	173.29.234.11	Plum Communications, LLC	Limited Liability Company	1018 NW Campus Ridge Court	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-29	Brian Shearer	brian@plumllc.com	Ankeny	Polk	Iowa	Kathryn Shearer	Emily Davis	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Dean Shearer	brian@plumllc.com	Self	Ankeny	Polk	Iowa	Kathryn Shearer	Emily Davis	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
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
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
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
289	2020-10-23 14:42	Anonymous (not verified)	65.103.82.36	Go Green Lawn and Tree	Proprietorship	2911 N Harrison st Davenport IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-23	Brandon	gogreenlawnandtree@yahoo.com	davenport	scott	iowa	Kayla Artioli	Eric Johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	brandon gordon	gogreenlawnandtree@yahoo.com	self	davenport	scott	ia	kayla	eric	Signed
1431	2023-01-25 16:24	Anonymous (not verified)	172.56.249.51	Warren transport	Limited Liability Company	3124 titan trail Waterloo,iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-25	Lamarcaus Lunford	universalvoyager1@gmail.com	Elkhart	IN	Indiana	Quinetta shead	Eric fikes	Signed	(1) The employer does not elect the employers’ liability coverage.	Lamarcaus Lunford	universalvoyager1@gmail.com	Owner	Elkhart	IN	Indiana	Quinetta shead	Eric fikes	Signed
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
1649	2023-05-16 11:37	Anonymous (not verified)	94.188.205.175	DEL-TA RESOURCE STAFFING, LLC	Limited Liability Company	17735 pinyon lane, Dallas TX 75252	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Solomon Solomon	solomon@del-taresourcestaffing.com	Dallas	Dallas	TX	John Effang	Eric Ijie	Signed	(1) The employer does not elect the employers’ liability coverage.	Registered Agents Inc 315 E 5th St, STE 202	agent@washingtonregisteredagent.com	Owner	Waterloo	Waterloo	IA	John Effang	Eric Ijie	Signed
252	2020-09-09 10:38	Anonymous (not verified)	65.103.82.36	KNS	Proprietorship	PO Box 2632	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-04	Keith N Slyter	KNSCONST@gmail.com	Davenport	Scott	Iowa	Eric Johnson	Dawn Tague	Signed	(1) The employer does not elect the employers’ liability coverage.	Keith N Slyter	knsconst@gmail.com	self	Davenport	Scott	Ia	Dawn Tague	Eric Johnson	Signed
276	2020-10-08 12:55	Anonymous (not verified)	65.103.82.36	Ron Ray	Limited Liability Company	311 N Division Creston Iowa 50801	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-08	Ron L Ray	641-782-0521@gmail.com	Creston	Union	Iowa	Kayla Artioli	Eric Johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron L Ray	641-782-0521@gmail.com	Self	Creston	Union	Iowa	Kayla Artioli	Eric Johnson	Signed
320	2020-11-17 10:08	Anonymous (not verified)	65.103.82.36	Brian Behnkendorf dba Dutchmen Services	Proprietorship	55 Rose Court West, Geneseo IL 61254	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-11-13	Brian Behnkendorf	4gbbehnk@gmail.com	Geneseo	Henry	Illinois	Kayla Artioli	Eric Johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Behnkendorf	4gbbehnk@gmail.com	Self	Geneseo	Henry	Illinois	Kayla Artioli	Eric Johnson	Signed
424	2021-03-05 15:56	Anonymous (not verified)	65.103.82.36	Guardian Angel Specialty Cleaners	Proprietorship	1018 W 14th Street, Davenport IA 52804	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-18	Leesa Monson	LMonson@gmail.com	Davenport	Scott	Iowa	Dawn Tague	Eric Johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	Leesa Monson	LMonson@gmail.com	Self	Davenport	Scott	Iowa	Dawn Tague	Eric Johnson	Signed
425	2021-03-05 16:03	Anonymous (not verified)	65.103.82.36	Ryan Richard	Proprietorship	1425 W 34th Street, 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.	2020-06-15	Ryan Richard	RRichard@gmail.com	Davenport	Scott	Iowa	Dawn Tague	Eric Johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Richard	RRichard@gmail.com	Self	Davenport	Scott	Iowa	Dawn Tague	Eric Johnson	Signed
1046	2022-04-14 08:11	Anonymous (not verified)	104.36.120.68	jet drywall	Limited Liability Company	5611 westminster DR #5 cedarfalls 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.	2022-04-14	murion jones	jetdrywall.construction@gmail.com	cedarfalls	black hawk	iowa	murion parely jones	murion jones	Signed	(1) The employer does not elect the employers’ liability coverage.	murion jones	jetdrywal.construction@gmail.com	owner	cedarfalls	black hawk	iowa	Murion Jones JR	Eric Jones	Signed
1047	2022-04-14 08:11	Anonymous (not verified)	104.36.120.68	jet drywall	Limited Liability Company	5611 westminster DR #5 cedarfalls 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.	2022-04-14	murion jones	jetdrywall.construction@gmail.com	cedarfalls	black hawk	iowa	murion parely jones	murion jones	Signed	(1) The employer does not elect the employers’ liability coverage.	murion jones	jetdrywal.construction@gmail.com	owner	cedarfalls	black hawk	iowa	Murion Jones JR	Eric Jones	Signed
267	2020-09-22 07:04	Anonymous (not verified)	74.84.65.174	Angel Jesus Argueta	Proprietorship	1523 Arlington Ave Des Moines, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-22	Angel Jesus Argueta	Juanargueta22@yahoo.com	Des Moines	Polk	Iowa	Larry Eugene Guire	Eric Michael West	Signed	(1) The employer does not elect the employers’ liability coverage.	Angel Jesus Argueta	Juanargueta22@yahoo.com	Same	Des Moines	Polk	Iowa	Larry Eugene Guire	Eric Michael West	Signed
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
460	2021-04-05 15:24	Anonymous (not verified)	173.20.169.155	Tim Stiles	Proprietorship	726 Grant St PO box 217 Dexter Iowa 50070	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-04	Tim Stiles	timcolleenstiles@gmail.com	Dexter	Dallas	Iowa	Karen Penton	ERIC TIERNAN	Signed	(1) The employer does not elect the employers’ liability coverage.	Tim Stiles	timcolleenstiles@gmail.com	Same Tim Stiles	Dexter	Dallas	Iowa	Karen Penton	Eric Tiernan	Signed
831	2022-01-12 15:10	Anonymous (not verified)	67.212.111.166	Cory's Painting LLC	Limited Liability Company	Po Box 1161 Cedar Falls, Iowa 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-12	Kyle Alan Schultz	schultzkyle01@gmail.com	Cedar Falls	Black Hawk County	Iowa	Kari Houle	Erica Schultz	Signed	(1) The employer does not elect the employers’ liability coverage.	Cory Allen Koger	coryspainting@gmail.com	Self	Cedar Falls	Black Hawk County	Iowa	Kari Houle	Erica Schultz	Signed
477	2021-04-14 11:04	Anonymous (not verified)	65.103.82.36	Lisa Kuhn	Proprietorship	427 s Concord Davenport IA 52802	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-09	Lisa Kuhn	none@hotmail.com	davenport	Scott	IA	Sarah	Erick	Signed	(1) The employer does not elect the employers’ liability coverage.	Lisa Kuhn	none@hotmail.com	self	davenport	scott	IA	sarah	erick	Signed
1021	2022-03-30 11:20	Anonymous (not verified)	173.18.22.217	Arti Concrete	Limited Liability Company	6901 SE 14th St Lot #226 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.	2022-03-30	Gerson David Artero	arti.concrete31@gmail.com	Des Moines	Polk	IA	Lesa Reeves	Erick Schuldt	Signed	(1) The employer does not elect the employers’ liability coverage.	Gerson David Artero	arti.concrete31@gmail.com	Owner	Des Moines	Polk	IA	Lesa Reeves	Erick Schuldt	Signed
1205	2022-07-14 13:29	Anonymous (not verified)	173.18.22.217	Residence Electric LLC	Limited Liability Company	5465 Mills Civic Pkwy #317 West Des Moines 50266	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-14	Anthony Rivera	residenceelectric@outlook.com	West Des Moines	Polk	Iowa	Lesa Reeves	Erick Schuldt	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony Rivera	residenceelectric@outlook.com	Owner	West Des Moines	Polk	Iowa	Lesa Reeves	Erick Schuldt	Signed
1359	2022-11-04 10:48	Anonymous (not verified)	173.18.22.217	Lewis Enterprises	Limited Liability Company	2723 Witmer Street 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.	2022-11-04	Corey Lewis	coreyboy1990@gmail.com	Des Moines	Polk	Iowa	Kelly Coluzzi	Erick Schuldt	Signed	(1) The employer does not elect the employers’ liability coverage.	Corey Lewis	coreyboy1990@gmail.com	Owner	Des Moines	Polk	Iowa	Kelly Coluzzi	Erick Schuldt	Signed
1490	2023-03-03 10:31	Anonymous (not verified)	94.188.205.175	Bagby Lawncar and More	Limited Liability Company	921 Pleasant Street, Des Moines IA 50309	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Cory Michael Bagby	bagbylawncareandmore@gmail.com	921 Pleasant Street	Polk	Iowa	Kelly Coluzzi	Erick Schuldt	Signed	(1) The employer does not elect the employers’ liability coverage.	Cory Bagby	babylawncareandmore@gmail.com	Owner	Des Moines	Polk	Iowa	Kelly Coluzzi	Erick Schuldt	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
1193	2022-07-08 10:18	Anonymous (not verified)	173.18.22.217	OWWT	Limited Liability Company	1915 SE Clovere Ridge Dr. Ankeny IA 50021	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-08	Robert M Jackson	dgfl08051982@gmail.com	Ankeny	Polk	IA	Lesa Reeves	Erick Schuldt	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert M Jackson	dgfl08051982@gmail.com	Owner	Ankeny	Polk	Iowa	Lesa Reeves	Erick Sculdt	Signed
1190	2022-07-07 12:00	Anonymous (not verified)	172.243.111.71	Breuer Earthworks Inc.	Proprietorship	4512 148th Ave 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.	2022-07-07	William Breuer	breuerearthworks@gmail.com	Burlington	Des Moines	Iowa	Donald Breuer	Ericka Breuer	Signed	(1) The employer does not elect the employers’ liability coverage.	William Breuer	breuerearthworks@gmail.com	Owner of Breuer Earthworks Inc.	BURLINGTON	Iowa	United States	Donald Breuer	Ericka Breuer	Signed
835	2022-01-12 17:41	Anonymous (not verified)	67.212.111.166	Cory's Painting LLC	Limited Liability Company	Po Box 1161 Cedar Falls, Iowa 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-13	Brian Christopher Armbruster	crossespalms42@gmail.com	Waterloo	Black Hawk County	Iowa	Kari Houle	Erik Bjorn Nelson	Signed	(1) The employer does not elect the employers’ liability coverage.	Cory Koger	coryspainting@gmail.com	Self	Cedar Falls	Black Hawk County	Iowa	Kari Houle	Erik Bjorn Nelson	Signed
1528	2023-03-22 10:37	Anonymous (not verified)	94.188.205.175	Uhl Cattle Company	Partnership	3329 Ozark Ave, Mapleton IA 51034	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Tonya Jean Uhl	tonyajuhl@gmail.com	Mapleton	Woodbury	iowa	Keaten Anthony Miller	Erik Michael Boyle	Signed	(1) The employer does not elect the employers’ liability coverage.	Tonya Jean Uhl	tonyajuhl@gmail.com	Owner	Mapleton	Woodbury	Iowa	Keaten Anthony Miller	Erik Michael Boyle	Signed
1529	2023-03-22 10:40	Anonymous (not verified)	94.188.205.175	Uhl Cattle Company	Partnership	3329 Ozark Ave, Mapleton IA 51034	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Troy Michael Uhl	troyuhl1224@gmail.com	Mapleton	Woodbury	Iowa	Keaten Anthony Miller	Erik Michael Boyle	Signed	(1) The employer does not elect the employers’ liability coverage.	Tonya Jean Uhl	tonyajuhl@gmail.com	Brother	Mapleton	Woodbury	Iowa	Keaten Anthony Miller	Erik Michael Boyle	Signed
99	2020-03-23 16:47	Anonymous (not verified)	216.96.116.78	B’s Sweet Treats	Proprietorship	21484 196th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-23	Brandi Wehr	brndwehr54@hotmail.com	Sigourney	Keokuk	IA	Erik Wehr	Brenda Workman	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandi Wehr	brndwrhr54@hotmail.com	Self	Sigourney	Keokuk	IA	Brenda Workman	Erik Wehr	Signed
977	2022-03-15 12:04	Anonymous (not verified)	38.108.136.192	Gunner Fogle	Proprietorship	307 S. Franklin St. Corydon, IA 50060	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-15	Gunner Lee Fogle	gunnerfogle@hotmail.com	Corydon	Wayne	IA	Jeremy Fogle	Erika Fogle	Signed	(1) The employer does not elect the employers’ liability coverage.	Gunner Fogle	gunnerfogle@hotmail.com	Myself	Corydon	Wayne	IA	Jeremy Fogle	Erika Fogle	Signed
1211	2022-07-18 14:10	Anonymous (not verified)	172.58.85.43	Palomeque Gutter LLC	Limited Liability Company	2004 se 24th 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.	2022-07-18	Philips Palomeque	ecuaphilips94@gmail.com	Des Moines IA	USA	Iowa	Philips Peter Palomeque Vallejo	Philips Palomeque	Signed	(1) The employer does not elect the employers’ liability coverage.	Philips Palomeque	ecuaphilips94@gmail.com	Owner	Des Moines	USA	Iowa	Philips Peter Palomeque Vallejo	Erika Zapata	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
78	2020-02-25 09:35	Anonymous (not verified)	65.127.131.118	Rey Construction, LLC	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.	2020-02-02	Juan Raymundo Hernandez	reyano43@gmail.com	Des Moines	polk	iowa	Rigoberto Mayorga	Y Bounv Quang	Signed	(1) The employer does not elect the employers’ liability coverage.	Preferred Interior Construction INC dba PIC INC	deb@piciowa.com	PIC, INC-contractor, Rey Construction, LLC-subcontractor	Altoona	IA	United States	Martin Pinon	Evan Bianchi	Signed
153	2020-05-12 12:58	Anonymous (not verified)	172.58.86.150	Big Head Burger	Limited Liability Company	706 Quincy st. Waterloo, Iowa 50703	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-12	David Westley Bryant	questions.bhb@gmail.com	Waterloo	Black Hawk	Iowa	Darlean Crawford	Everlue Kincaid	Signed	(1) The employer does not elect the employers’ liability coverage.	David Westley Bryant	questions.bhb@gmail.com	Owner	Waterloo	Black Hawk	Iowa	Darlean Crawford	Everlue Kincaid	Signed
2109	2024-03-21 11:15	Anonymous (not verified)	94.188.205.169	Panameno Stone	Proprietorship	3701 SE 18th Ct. 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.	2024-03-21	Domingo Panameno	albertpana08@gmail.com	Des Moines	Polk	Iowa	Drakkar Rapaich	Fabi Palomares	Signed	(1) The employer does not elect the employers’ liability coverage.	Domingo Panameno	albertpana08@gmail.com	Self	Des Moines	Polk	Iowa	Drakkar Rapaich	Fabi Palomares	Signed
2110	2024-03-21 13:29	Anonymous (not verified)	94.188.205.174	Baroga Stone Masonry LLC	Proprietorship	1228 Loomis Ave Des Moines, IA 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-21	Bacilio Rodriguez	barogastonemasonry@gmail.com	Des Moines	Polk	Iowa	Drakkar Rapaich	Fabi Palomares	Signed	(1) The employer does not elect the employers’ liability coverage.	Bacilio Rodriguez	barogastonemasonry@gmail.com	Self	Des Moines	Polk	Iowa	Drakkar Rapaich	Fabi Palomares	Signed
2122	2024-03-28 10:15	Anonymous (not verified)	94.188.205.169	Stone Villalobos LLC	Limited Liability Company	4231 Morton 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.	2024-03-28	Josue Villalobos	villalobosjosue2016@gmail.com	Des Moines	Polk	Iowa	Edgar Palomares	Fabiola Palomares Recendiz	Signed	(1) The employer does not elect the employers’ liability coverage.	Josue Villalobos	villalobosjosue2016@gmail.com	Self	Des Moines	Polk	Iowa	Edgar Palomares	Fabiola Palomares Recendiz	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
442	2021-03-22 12:14	Anonymous (not verified)	149.20.235.228	Tim Bruck Construction Inc.	Proprietorship	348 Highway 44 Rd. Porstmouth, IA 51565	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-22	Timothy Richard Bruck	timrbruck@gmail.com	Portsmouth	Shelby	Iowa	Heath Ryan Stein	Faith Nicole Bruck	Signed	(1) The employer does not elect the employers’ liability coverage.	Tim Richard Bruck	timrbruck@gmail.com	Self	Portsmouth	Shelby	Iowa	Heath Ryan Stein	Faith Nicole Bruck	Signed
1705	2023-06-23 16:01	Anonymous (not verified)	94.188.205.176	MV Carpentry LLC	Limited Liability Partnership	32724 U.S. 69 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.	2023-06-23	Carlos Moreno	Silencitopunk@gmail.com	Huxley	IA	United States	Alejandro Colin	Fermin Luz	Signed	(1) The employer does not elect the employers’ liability coverage.	Carlos Moreno	silencitopunk@gmail.com	Husband	Huxley	IA	United States	Alejandro Colin	Fermin Luz	Signed
682	2021-10-19 16:15	Anonymous (not verified)	65.144.174.26	BBR Tile and Professional Installation LLC	Proprietorship	903 School Ave Norwalk, IA 50211	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-19	Bertin Baltazar	baltarey2009@gmail.com	Norwalk	Warren	Iowa	Enedelia Bonilla	Fernando Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Bertin Baltazar	baltarey2009@gmail.com	Owner	Norwalk	Warren	Iowa	Enedelia Bonilla	Fernando Garcia	Signed
439	2021-03-18 08:09	Anonymous (not verified)	172.58.86.251	Nancy Lopez/Lifetime Roofing and Construction Corpn	Proprietorship	2234 Highland St 50315 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.	2021-03-18	Nancy Lopez/ Lifetime Roofing and Construction Corp	info@lifetimeroofingdsm.com	Des Moines	Polk	I A	Noe Ordaz	Fidel Rubio	Signed	(1) The employer does not elect the employers’ liability coverage.	Nancy Lopez	info@lifetimeroofingdsm.com	Owner	Des Moines	Polk	IA	Noe Ordaz	Fidel Rubio	Signed
667	2021-10-11 19:33	Anonymous (not verified)	104.166.240.24	FS Custom Flooring	Limited Liability Company	5729 NW 92nd 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.	2021-10-11	Filip Sakanovic	filip@fscustomflooring.com	Johnston	IA	United States	Senad Sakanovic	Filip Sakanovic	Signed	(1) The employer does not elect the employers’ liability coverage.	FS Tiling and Ceramics	filip@fscustomflooring.com	N/A	Johnston	IA	United States	Senad Sakanovic	Filip Sakanovic	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
210	2020-07-20 13:28	Anonymous (not verified)	75.162.95.97	RM construction	Proprietorship	65 SE 5TH STREET APT 4 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.	2020-07-20	Rafael Marquez	marquezrafael1@outlook.com	Des Moines	Polk IOWA	IOWA	Richard Yanez	Francisco Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Rafael Marquez	marquezrafael1@outlook.com	owner	Des Moines	Polk	IOWA	Richard Yanez	Francisco Garcia	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
1145	2022-06-07 11:14	Anonymous (not verified)	173.30.72.62	Swifty Enterprises	Limited Liability Company	1134 Capri Drive 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.	2022-06-07	Daniel Tabaka	dmtabaka1@gmail.com	Cedar Rapids	Linn	IA	Wilma Janacek	Fredrick Janacek	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Tabaka	dmtabaka1@gmail.copm	Self	Cedar Rapids	Linn	IA	Wilma Janacek	Fredrick Janacek	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
1198	2022-07-11 15:46	Anonymous (not verified)	74.84.91.178	Dave's Remodeling LLC	Limited Liability Company	2308 Long Grove Ct, 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.	2022-06-01	Kim Kern	davesremodeling@aol.com	Asbury	Dubuque	Iowa	Brenda Lewis	Gabe Drewlow	Signed	(1) The employer does not elect the employers’ liability coverage.	Kim Kern	davesremodeling@aol.com	co-owner	Asbury	Dubuque	Iowa	Brenda Lewis	Gabe Drewlow	Signed
1943	2023-12-06 16:34	Anonymous (not verified)	94.188.207.230	Your Neighbors Pressure Washing LLC	Limited Liability Company	2059 Lyon St Des Moines Iowa 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-06	Alejandro Bacano Rodriguez	alejandrobacanorodriguez@gmail.com	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Alejandro Bacano Rodriguez	alejandrobacanorodriguez@gmail.com	Myself	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed
1944	2023-12-06 16:41	Anonymous (not verified)	94.188.207.226	Sell Now Iowa	Limited Liability Company	5525 Meredith Dr Suite B Des Moines, Iowa 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-06	Alejandro Bacano Rodriguez	alejandrobacanorodriguez@gmail.com	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Sale Now Iowa	team@sellnowiowa.com	None	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed
1945	2023-12-06 16:47	Anonymous (not verified)	94.188.205.169	Sell Now Iowa	Limited Liability Company	5525 Meredith Drive Suite B Des Moines Iowa 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-06	Alejandro Bacano Rodriguez	alejandrobacanorodriguez@gmail.com	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Sell Now Iowa	team@sellnowiowa.com	None	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed
1946	2023-12-06 16:51	Anonymous (not verified)	94.188.205.168	Blue Sky Renovations Iowa LLC	Limited Liability Company	2059 Lyon St Des Moines Iowa 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-06	Alejandro Bacano Rodriguez	alejandrobacanorodriguez@gmail.com	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Sell Now Iowa	team@sellnowiowa.com	None	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed
313	2020-11-11 20:35	Anonymous (not verified)	174.198.78.148	Wilson Snow Maintenance	Proprietorship	3518 183rd Avenue, Carlisle, Iowa 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.	2020-11-11	Bruce E. Wilson	bewilson83@gmail.com	Carlisle	Warren	Iowa	Kristen Wilson	Garett Wilson	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Bruce Wilson	bewilson83@gmail.com	self	Carlisle	Warren	Iowa	Kristen Wilson	Garett Wilson	Signed
1114	2022-05-17 15:30	Anonymous (not verified)	67.212.117.198	Busta Painting	Limited Liability Company	610 W 26th st #1 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.	2022-05-16	Evan Busta	bustapainting@gmail.com	Cedar Falls	IA	United States	Tanner Heikens	Garrett Burrack	Signed	(1) The employer does not elect the employers’ liability coverage.	Evan Busta	bustapainting@gmail.com	Self Employeed	Cedar Falls	IA	United States	Tanner Heikens	Garrett Burrack	Signed
1411	2023-01-06 12:35	Anonymous (not verified)	72.255.93.91	Amayas Painting	Proprietorship	1501 Mattern Ave, 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.	2022-11-01	Carlos Alexando Amaya Garcia	bmoellers@thebookkeepersinc.net	Des moines	Polk	IA	Tammy Robbins	Gary Cort	Signed	(1) The employer does not elect the employers’ liability coverage.	Brett Moelles	bmoellers@thebookkeepersinc.net	Accountant	Des Moines	Polk	IA	Tammy Robbins	Gary Cort	Signed
1412	2023-01-06 12:38	Anonymous (not verified)	72.255.93.91	Espindola Painting Services	Proprietorship	4701 Woodland Ave Unit 3, 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.	2022-09-07	Hugo Espindola	bmoellers@thebookeepersinc.net	Des Moines	Polk	IA	Jenny Espindola	Gary Cort	Signed	(1) The employer does not elect the employers’ liability coverage.	Brett Moellers	bmoellers@thebookkeepersinc.net	Accountant	Des Moines	Polk	IA	Jenny Espindola	Gary Cort	Signed
1918	2023-11-21 12:45	Anonymous (not verified)	94.188.205.167	515 PAINTING LLC	Limited Liability Company	PO Box 157, Berwick, IA 50032	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Marvin Parker	gcort06@gmail.com	Berwick	Polk	Iowa	Dillon Parker	Gary Cort	Signed	(1) The employer does not elect the employers’ liability coverage.	Marvin Parker	gcort06@gmail.com	Owner	Berwick	Polk	Iowa	Dillon Parket	Gary Cort	Signed
1570	2023-04-12 18:09	Anonymous (not verified)	94.188.205.166	Staley Engineering Consultants, LLC	Limited Liability Company	4212 Holland Drive, 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.	2023-04-12	Donald K Staley	Don.Staley@q.com	Des Moines	Iowa	United States	Kendall S. Staley	Gary D. Hlavka	Signed	(1) The employer does not elect the employers’ liability coverage.	Donald K Staley	Don.Staley@q.com	Owner	Des Moines	Iowa	United States	Kendall S. Staley	Gary D. Hlavka	Signed
1725	2023-07-07 13:37	Anonymous (not verified)	94.188.205.167	Liana Fatino	Limited Liability Company	1930 se 14th des moines iowa 50321	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Liana Fatino	lfatino@yahoo.com	des moines	USA	Iowa	Liana Fatino	Gary Fatino	Signed	(1) The employer does not elect the employers’ liability coverage.	Liana Fatino	lfatino@yahoo.com	wife	des moines	USA	iowa	Liana Fatino	Gary Fatino	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
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
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
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
982	2022-03-17 09:22	Anonymous (not verified)	65.132.173.234	DAVE GARDNER CONSTRUCTION	Proprietorship	11936 KIMBALL AVE WATERLOO IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-17	DAVE GARDNER	djg201312@gmail.com	Waterloo	Black Hawk	Iowa	Amy Picha	Gary Rankin	Signed	(1) The employer does not elect the employers’ liability coverage.	Dave Gardner	djg201312@gmail.com	self	Waterloo	Black Hawk	IA	Amy Picha	Gary Rankin	Signed
429	2021-03-10 12:52	Anonymous (not verified)	173.23.50.65	Raleigh Electrical Services	Limited Liability Company	3747 SE 10th 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.	2021-03-10	Timothy Bruce Raleigh	tim@raleighelectrical.org	Des Moines	Polk	Iowa	Joe Coughlon	Genna Prine	Signed	(1) The employer does not elect the employers’ liability coverage.	Timothy Bruce Raleigh	tim@raleighelectrical.org	Same	Des Moines	Polk	Iowa	Joe Coughlon	Genna Prine	Signed
970	2022-03-14 14:08	Anonymous (not verified)	174.199.79.176	Friends Transportation Services LLC	Limited Liability Company	6010 Creston Ave Unit 26, Des Moines, IA 50321	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-14	Mohammed Dood	mohedali777@hotmail.com	Des Moines	Polk	Iowa	Leigh Laven	Geoff Matlock	Signed	(1) The employer does not elect the employers’ liability coverage.	Mohammed Dood	mohedali777@hotmail.com	Owner	Des Moines	Polk	Iowa	Leigh Laven	Geoff Matlock	Signed
2134	2024-04-04 08:10	Anonymous (not verified)	94.188.205.169	TERRA CONSTRUCTION LLC	Limited Liability Company	621 Oak Park Ave 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.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2024-04-04	Bryce Shabazz	block.radio@yahoo.com	Des Moines	Polk	Iowa	Megan Donigan	George Hana	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jessica L Heller	Jessica.heller@adp.com	Insurance Agent	Allentown	Lehigh	PA	Megan Donigan	George Hana	Signed
536	2021-06-07 11:01	Anonymous (not verified)	205.221.255.62	Mark Lile	Limited Liability Partnership	PO Box 36411	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-06-07	Martin Luverne Humphrey Jr	martinhumphreu@gmail.com	Des Moines	Polk	Iowa	Jaimi Humphrey	George Porter	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Lile	Mark@ultimateautowash.com	Employer	Des Moines	Polk	Iowa	Jaimi Humphrey	George Porter	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
309	2020-11-09 12:17	Anonymous (not verified)	70.184.213.31	Gerald Gerhardt	Proprietorship	104 S 3rd Street, Villisca, IA 50864	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-03	Gerald Gerhardt	jerrygerhardt1280@gmail.com	Villisca	Montgomery	IA	Tony W. Johnson	Gerald Gerhardt	Signed	(1) The employer does not elect the employers’ liability coverage.	Smith Davis Insurance	tony@smithdavisins.com	Client	Papillion	Sarpy	IA	Tony W. Johnson	Gerald Gerhardt	Signed
581	2021-07-22 14:29	Anonymous (not verified)	205.221.255.62	MartinHumphrey	Limited Liability Company	Cummins Rd. Apt 202	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-22	Martin Luverne Humphrey Jr.	martinhumphreu@gmail.com	Des Moines	Polk	Ioea	George Porter	Gerald Lund	Signed	(1) The employer does not elect the employers’ liability coverage.	Martin Luverne Humphrey Jr	martinhumphreu@gmail.com	Self	Des Moines	Polk	Iowa	George Porter	Gerald Lund	Signed
822	2022-01-04 16:59	Anonymous (not verified)	173.22.62.131	Gerardo Calvillo	Limited Liability Company	1802 mondamin 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.	2022-01-04	Gerardo Calvillo	joedhsanchez@icloud.com	Des Moines	Polk	Iowa	Aurora Maciel colín	Gerardo Calvillo	Signed	(1) The employer does not elect the employers’ liability coverage.	Gerardo Calvillo	joedhsanchez@icloud.com	Self	Des Moines	Polk	Iowa	Aurora maciel colín	Gerardo Calvillo	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
1970	2023-12-29 10:01	Anonymous (not verified)	94.188.205.168	Beatrice Banura	Proprietorship	14511 Bentwood Dr, Urbandale IA 50323	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-29	Beatrice Banura	banurabeatrice4@gmail.com	Urbandale	Dallas	IA	Priscilla Saina	Gideon Saina	Signed	(1) The employer does not elect the employers’ liability coverage.	Beatrice Banura	banurabeatrice4@gmail.com	Self employed	Urbandale	IA	IA	Priscilla Saina	Gideon Saina	Signed
1512	2023-03-10 09:44	Anonymous (not verified)	94.188.205.169	eliseo isai	Proprietorship	5301 SE 24th St Des Moines, IA 50320 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.	2023-03-08	eliseo isai carranza perez	Misaelballeza40@gmail.com	desmoines	polk	iowa	Julio Nolvela	giovanni nolvela	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	eliseo isai carranza perez	Misaelballeza40@gmail.com	self	desmoines	polk	iowa	Julio Nolvela	giovanni nolvela	Signed
1251	2022-08-11 09:11	Anonymous (not verified)	174.255.1.226	Two Crew Remodeling and Maintenance	Limited Liability Partnership	11 C Ave Newhall, Iowa, 52315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-11	Trenten John Schafer	Twocrewremodeling@gmail.com	Newhall	Benton	Iowa	Joeseph Allen Alger	Glenn Mitchel Kieler	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan McArtor	Mcartorjordan@gmail.com	Part owner	cedar rapids	CEDAR RAPIDS, IA (Inside) LINN	Iowa	Joeseph Allen Alger	Glenn Mitchel Kieler	Signed
1420	2023-01-12 13:42	Anonymous (not verified)	75.162.144.157	Clearer Sky	Limited Liability Company	2305 Drake Park 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.	2023-01-12	Osvaldo Mayorga Delgado	grae1524@gmail.com	Des Moines	Polk	Iowa	Juan Manuel Mayorga Delgado	Gloria Lorena Enamorado Guzman	Signed	(1) The employer does not elect the employers’ liability coverage.	Osvaldo Mayorga Delgado	Grae1524@gmail.com	Self	Des Moines	Polk	Iowa	Juan Manuel Mayorga Delgado	Gloria Lorena Enamorado Guzman	Signed
118	2020-04-13 11:48	Anonymous (not verified)	173.26.152.222	Society of St. Vincent de Paul, District Council of Waterloo Iowa,Inc	Limited Liability Company	320 Broadway St PO Box 2727 Waterloo IA 50704	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-14	Joseph D. Sobczyk	joczyk@aol.com	Cedar Falls	Black Hawk	Iowa	George W. Karnick	Glynis R. Worthington	Signed	(1) The employer does not elect the employers’ liability coverage.	Joseph D. Sobczyk	joczyk@aol.com	self	Cedar Falls	Black Hawk	Iowa	George W. Karnick	Glynis R. Worthington	Signed
121	2020-04-14 15:11	Anonymous (not verified)	173.31.176.75	Society of St. Vincent de Paul, District council of Waterloo Iowa,Inc	Limited Liability Company	320 Broadway St PO Box 2727 Waterloo IA 50704	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-14	Michele E Collison	darmstad48@aol.com	Denver	Bremer	Iowa	George W. Karnick	Glynis R. Worthington	Signed	(1) The employer does not elect the employers’ liability coverage.	Joseph D. Sobczyk	joczyk@aol.com	Secretary of the St. Vincent de Paul District Council of Waterloo, Iowa, Inc.	Denver	Bremer	Iowa	George W. Karnick	Glynis R. Worthington	Signed
292	2020-10-27 18:15	Anonymous (not verified)	173.19.162.248	John Lass	Limited Liability Company	6025 SE 16TH 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.	2020-10-27	John Lass	johnwlass@gmail.com	Des Moines	IA	United States	Dawn Lass	Gordon Lamp Jr.	Signed	(1) The employer does not elect the employers’ liability coverage.	John Lass	johnwlass@gmail.com	self	Des Moines	IA	United States	Dawn Lass	Gordon Lamp Jr	Signed
1982	2024-01-11 12:29	Anonymous (not verified)	94.188.205.166	Grace Justine	Proprietorship	405 Northview 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.	2024-01-11	Grace Justine Wandera / Independent Contractor	justine.wandera@candeoiowa.org	Waukee	IA	IA	Grace Justine Wandera / Independent Contractor	Grace Justine Wandera / Independent Contractor	Signed	(1) The employer does not elect the employers’ liability coverage.	Grace Justine Wandera / Independent Contractor	justine.wandera@candeoiowa.org	own	Waukee	IA	IA	Grace Justine Wandera / Independent Contractor	Grace Justine Wandera / Independent Contractor	Signed
1379	2022-11-22 11:44	Anonymous (not verified)	166.181.89.236	365 Services LLC	Limited Liability Company	306 hayes st e hazleton iowa 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.	2022-11-22	Clayton marshall davis	Lcrc365@outlook.com	Hazleton	Bucanan	Iowa	Grace lilibridge	Kurt king	Signed	(1) The employer does not elect the employers’ liability coverage.	Clayton marshall davis	Lcrc365@outlook.com	Owner	Hazleton	Bucanan	Iowa	Kurt kind	Grace lilibridge	Signed
1020	2022-03-29 16:53	Anonymous (not verified)	207.32.60.144	J.A. Dahlhauser, Ltd.	Proprietorship	1741 Hwy. 7	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Jaylin A. Dahlhauser	jaydahlhauser@gmail.com	Newell	IA	United States	Matthew McClellan	Gracelin R. Dahlhauser	Signed	(1) The employer does not elect the employers’ liability coverage.	Jaylin A. DAhlhauser	jaydahlhauser@gmail.com	Owner	Newell	IA	United States	Matthew McClellan	Gracelin R. Dahlhauser	Signed
125	2020-04-20 19:01	Anonymous (not verified)	67.22.196.182	Driven School of Driving	Limited Liability Company	451 E 1st 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.	2020-04-20	Justin J. Franken	drivenschoolofdriving@gmail.com	Sioux Center	Sioux	IA	Robyn Franken	Gracyn Franken	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Franken	drivenschoolofdriving@gmail.com	Me	Sioux Center	Sioux	IA	Robyn Franken	Gracyn Franken	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
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
669	2021-10-13 08:24	Anonymous (not verified)	64.191.11.62	E360 Building Company, Inc.	Proprietorship	PO Box 363, 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.	2021-10-13	Mark Miller	mark@e360buildingco.com	Cedar Falls	Black Hawk	Iowa	Laetyn Miller	Grant Williamson	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Miller	markm@cfu.net	Self	Cedar Falls	Black Hawk	Iowa	Laetyn Miller	Grant Williamson	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
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
1642	2023-05-12 07:29	Anonymous (not verified)	94.188.205.169	HARI SWAMI LLC	Limited Liability Company	2759 Mt Pleasant St, 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.	2023-05-12	BRANDON KELLY	MARKWILLIAMSPRO@GMAIL.COM	FRUIT HEIGHTS	DAVIS	UTAH	MARK WILLIAMS	GREG VANCAMP	Signed	(1) The employer does not elect the employers’ liability coverage.	BRANDON KRLLY	MARKWILLIAMSPRO@GMAIL.COM	SELF	FRUIT HEIGHTS	DAVIS	UTAH	MARK WILLIAMS	GREG VANCAMP	Signed
866	2022-01-27 19:15	Anonymous (not verified)	199.66.15.25	Greg Cheno Services LLC	Limited Liability Company	203 N H St.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-27	Gregory Chenoweth	gregcheno@gmail.com	Indianola	IA	United States	Rebecca Sue Abbott	Gregory Blair Abbott	Signed	(1) The employer does not elect the employers’ liability coverage.	Gregory J. Chenoweth	gregcheno@gmail.com	Same	Indianola	Warren	Iowa	Rebecca Sue Abbott	Gregory Blair Abbott	Signed
314	2020-11-13 10:18	Anonymous (not verified)	66.172.192.197	Helaine W. Sherman Trust	Proprietorship	P.O. Box 717, Sioux City, Iowa 51102	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-11-13	Helaine W. Sherman Trust, A.F. Baron, Trustee	afbaron@baronsar.com	Sioux City	Woodbury	Iowa	Joni L. Stieneke	Gregory N. Lohr	Signed	(1) The employer does not elect the employers’ liability coverage.	Helaine W. Sherman Trust, A.F. Baron, Trustee	afbaron@baronsar.com	Trustee of Trust	Sioux City	Woodbury	Iowa	Joni L. Stieneke	Gregory N. Lohr	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
183	2020-06-12 08:23	Anonymous (not verified)	107.77.173.7	A&W Marble & Tile	Proprietorship	5624 Sw 5Th Pl	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-12	Wayne A Yergy	wyergy@gmail.com	Des Moines	IA	United States	Michael L Smith	Guy B Chaney	Signed	(1) The employer does not elect the employers’ liability coverage.	Wayne Yergy	wyergy@gmail.com	Self	Des Moines	IA	United States	Michael L Smith	Guy B Chaney	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
844	2022-01-20 08:55	Anonymous (not verified)	172.58.87.106	Barkley Coatings	Limited Liability Company	305 E 20th 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.	2022-01-20	Heath	barkleyheath@yahoo.com	Newton	United States	Iowa	Matthew Blunk	Hailey Scott	Signed	(1) The employer does not elect the employers’ liability coverage.	Heath Barkley	barkleyheath@yahoo.com	Owner	Newton	IA	United States	Matthew Blunk	Hailey Scott	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
414	2021-02-28 15:32	Anonymous (not verified)	174.198.75.211	Charlie Christian Hutt	Proprietorship	609 E. main 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.	2021-01-29	Charlie Christian Hutt	bmxican_04@hotmail.com	Brooklyn	poweshiek	IA	gene shafbough	hannah hutt	Signed	(1) The employer does not elect the employers’ liability coverage.	Charlie Christian Hutt	bmxican_04@hotmail.com	sole	Brooklyn	poweshiek	IA	gene shafbough	hannah hutt	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
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
1538	2023-03-27 15:20	Anonymous (not verified)	94.188.205.167	Luke Woods	Limited Liability Company	1513 Burnett Station Road Central City, IA 52214	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-27	Luke James Woods	woodsmencontractingllc@gmail.com	Central City	Linn	Iowa	Keith John Woods	Heath John Woods	Signed	(1) The employer does not elect the employers’ liability coverage.	Luke James Woods	woodsmencontractingllc@gmail.com	same person	Central City	Linn	Iowa	Keith John Woods	Heath John Woods	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
715	2021-11-05 11:27	Anonymous (not verified)	209.252.172.87	Ken Clifford	Proprietorship	132121st Ave SW Cedar Rapids, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-18	Ken Clifford	ken40406108@gmail.com	Cedar Rapids	Linn	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Ken Clifford	ken40406108@gmail.com	Self Employer	Cedar Rapids	Linn	Iowa	Sarah Coberley	Heather Howell	Signed
716	2021-11-05 13:22	Anonymous (not verified)	209.252.172.87	Rick Clifford Clifford Custom Tile & Flooring	Proprietorship	1563 Palmer Ct NE, Solon, IA 52333	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-24	Rick Clifford	cliffordcustomtile@gmail.com	Solon	Johnson	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Clifford Clifford Custom Tile & Flooring	cliffordcustomtile@gmail.com	Self Employed	Solon	Johnson	Iowa	Sarah Coberley	Heather Howell	Signed
717	2021-11-05 13:32	Anonymous (not verified)	209.252.172.87	Nick Wiles CW Flooring LLC	Limited Liability Company	Po Box 445, 710 6th St Wellman, IA 52356	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-24	Nick Wiles CW Flooring LLC	nickwiles007@gmail.com	Wellman	Washington	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Nick Wiles CW Flooring LLC	nickwiles007@gmail.com	Self Employed	Wellman	Washington	Iowa	Sarah Coberley	Heather Howell	Signed
718	2021-11-05 13:41	Anonymous (not verified)	209.252.172.87	Wayne Hunt	Proprietorship	405 E 4th St Tipton, Ia 52772	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-12	Wayne Hunt	installation@bachmeiercarpetone.com	Tipton	Cedar	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Wayne Hunt	installation@bachmeiercarpetone.com	Self	Tipton	Cedar	Iowa	Sarah Coberley	Heather Howell	Signed
721	2021-11-05 14:04	Anonymous (not verified)	209.252.172.87	Mike Kraus	Proprietorship	212 2nd St Buffalo, Ia 52728	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-17	Mike Kraus	mjkraus4356@gmail.com	Buffalo	Scott	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Mike Kraus	mjkraus4356@gmail.com	Self Employed	Buffalo	Scott	Iowa	Sarah Coberley	Heather Howell	Signed
722	2021-11-05 14:07	Anonymous (not verified)	209.252.172.87	Jeremiah Lunsford	Proprietorship	624 Carroll Dr SE, Cedar Rapids, IA 52403	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-10	Jeremiah Lundsford	jjaylunsford@gmail.com	Cedar Paids	Linn	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeremiah Lunsford	jjaylunsford@gmail.com	Self Employed	Cedar Rapids	Linn	Iowa	Sarah Coberley	Heather Howell	Signed
723	2021-11-05 14:13	Anonymous (not verified)	209.252.172.87	Will Lacina Northstar Hardwood Floors	Proprietorship	1211 G St Amana, IA 52203	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-16	Will Lacina	northstarhardwoodfloor@gmail.com	Amana	Iowa	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	William Lacina	northstarhardwoodfloor@gmail.com	Self Employed	Amana	Iowa	Iowa	Sarah Coberley	Heather Howell	Signed
724	2021-11-05 14:25	Anonymous (not verified)	209.252.172.87	Josh Peterson	Proprietorship	121 Karen Drive, Williamsburg, IA 52361	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-15	Josh Peterson	tanyataz@msn.com	Williamsburg	Iowa	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Peterson	tanyataz@msn.com	Self Employed	Williamsburg	Iowa	Iowa	Sarah Coberley	Heather Howell	Signed
725	2021-11-05 14:32	Anonymous (not verified)	174.198.66.202	Jay Schulte	Proprietorship	7530 Prairie Hawk Dr Sw, Cedar Rapids, Ia 52404	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-15	Jay Schulte	schultejay@Hotmail.com	Cedar Rapids	Linn	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Jay Schulte	schultejay@hotmail.com	Self Employed	Cedar Rapids	Linn	Ia	Sarah Coberley	Heather Howell	Signed
726	2021-11-05 14:39	Anonymous (not verified)	174.198.66.202	John Stoltzfus JM Tile LLC	Limited Liability Company	Wellman, Ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-19	John Stoltzfus	installation@bachmeiercarpetone.com	Wellman	Washington	Iowa	Sarah Coberley	Heather Howell	Signed	(1) The employer does not elect the employers’ liability coverage.	John Stoltzfus	installation@bachmeiercarpetone.com	Self	Wellman	Washington	Iowa	Sarah Coberley	Heather Howell	Signed
727	2021-11-05 14:46	Anonymous (not verified)	174.198.66.202	Bret Swift Swift Enterprises	Proprietorship	2240 Coldstream Drive 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.	2020-01-13	Brett Swidt	swiftenterprises@me.com	Cedar Rapids	Linn	Iowa	Sarah Coberley	Heather Howell	Signed	(1) The employer does not elect the employers’ liability coverage.	Bret Swift	swiftenterprises@me.com	Self Employed	Cedar Rapids	Linn	Iowa	Sarah Coberley	Heather Howell	Signed
728	2021-11-05 14:52	Anonymous (not verified)	209.252.172.87	Stacy Wade Wade Flooring Specialist	Proprietorship	2481 247th St, Washington, IA 52353	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-15	Stacy Wade	stacywade92@gmail.com	Washington	Washington	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Stacy Wade	stacywade92@gmail.com	Self	Washington	Washington	Iowa	Sarah Coberley	Heather Howell	Signed
729	2021-11-05 15:25	Anonymous (not verified)	209.252.172.87	Joshua Yoder S&S Window Treatments	Proprietorship	2555 Hwy 1 SW, Iowa City Iowa 52240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-20	Joshua Yoder	installation@bachmeiercarpetone.com	Iowa City	Johnson	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua Yoder	installation@bachmeiercarpetone.com	Owner	Iowa City	Johnson	Iowa	Sarah Coberley	Heather Howell	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
1074	2022-04-27 12:16	Anonymous (not verified)	66.129.216.227	Kristyn M Gerst Counseling LLC	Limited Liability Company	30 Villager Dr. Apt. 3 North Liberty, IA 52317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-27	Kristyn May Gerst	kmwatson18@gmail.com	North Liberty	johnson	Iowa	Forrest John Gerst	Heather Lynn Watson	Signed	(1) The employer does not elect the employers’ liability coverage.	Kristyn May Gerst	kmwatson18@gmail.com	self	North Liberty	Johnson	Iowa	Forrest John Gerst	Heather Lynn Watson	Signed
1370	2022-11-13 19:49	Anonymous (not verified)	174.213.144.30	Iowa’s Gutter Specialist	Limited Liability Company	1390 Lark 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.	2022-10-21	Dustin Halverson	dh42312695@gmail.com	Hampton	IA	United States	Patricia Reynolds	Heather Halverson	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin Halverson	dh42312695@gmail.com	Owner	Hampton	IA	United States	Patricia Marie Reynolds	Heather Marie Halverson	Signed
705	2021-11-02 11:41	Anonymous (not verified)	173.23.180.159	Simri Enterprise LLC	Limited Liability Company	614 Ricker St Waterloo, IA 50703	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-02	Noemi Del Carmen Trinidad	simdelenterprisellc@gmail.com	Waterloo	Black Hawk	Iowa	Karla Axume	Helmer Linares	Signed	(1) The employer does not elect the employers’ liability coverage.	Simri Y Aldana	simdelenterprisellc@gmail.com	Owner	Waterloo	Black Hawk	Iowa	Karla Axume	Helmer Linares	Signed
707	2021-11-03 15:30	Anonymous (not verified)	173.23.180.159	Simdel Enterprise LLC	Limited Liability Company	614 Ricker St Waterloo, IA 50703	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-03	Noemi Del Carmen Trinidad	simdelenterprisellc@gmail.com	Waterloo	Black Hawk	Iowa	Karla Axume	Helmer Linares Axume	Signed	(1) The employer does not elect the employers’ liability coverage.	Simri Y Aldana	simdelenterprisellc@gmail.com	Owner	Waterloo	Black Hawk	Iowa	Karla Axume	Helmer Linares Axume	Signed
708	2021-11-03 15:37	Anonymous (not verified)	173.23.180.159	Simdel Enterprise LLC	Limited Liability Company	614 Ricker St. Waterloo, IA 50703	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-03	Simri Yonelda Aldana Leiva	simdelenterprisellc@gmail.com	Waterloo	Black Hawk	Iowa	Karla Axume	Helmer Linares Axume	Signed	(1) The employer does not elect the employers’ liability coverage.	Noemi Del Carmen Trinidad	simdelenterprisellc@gmail.com	Owner	Waterloo	Black Hawk	Iowa	Karla Axume	Helmer Linares Axume	Signed
791	2021-12-14 11:35	Anonymous (not verified)	108.178.194.186	Leaf Home solutions LLC	Limited Liability Company	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.	2023-12-14	Abelardo Lino Montes	alinomontes@gmail.com	Le claire IA 52753	Scott	Iowa	Ann Pelton	Herman Roche	Signed	(1) The employer does not elect the employers’ liability coverage.	Abelardo Lino Montes	alinomontes@gmail.com	Owner	Le Claire	Scott	IA	Ann Pelton	Herman Roche	Signed
771	2021-11-22 20:29	Anonymous (not verified)	75.162.65.250	Art Flooring LLC	Limited Liability Company	1225 Emma Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-23	Antonio Rojas	artfloorsllc@gmail.com	1225 Emma Ave	Polk	Iowa	Antonio Rojas	Hilda Rojas	Signed	(1) The employer does not elect the employers’ liability coverage.	Antonio Rojas	artfloorsllc@gmail.com	self	same as above	same as above	iowa	Antonio Rojas	Hilda Rojas	Signed
1123	2022-05-22 14:32	Anonymous (not verified)	173.24.108.210	Daly Building Service, LLC	Limited Liability Company	409 Dammann Dr. 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.	2022-05-22	Noah Taylor Daly	Noahdalyubs@Gmail.com	Eldridge	Scott County	Iowa	Corinna Daly	Holly Roberts	Signed	(1) The employer does not elect the employers’ liability coverage.	Noah Taylor Daly	Noahdalyubs@Gmail.com	Owner	Eldridge	Scott County	Iowa	Corinna Daly	Holly Roberts	Signed
2195	2024-04-30 15:31	Anonymous (not verified)	94.188.205.166	Jason Cooper	Proprietorship	1181 Western Ave Stockton Iowa 52769	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-30	Jason cooper	jvcpainting88@gmail.com	Stockton	IA	United States	Violet minssen	Hope Bishop	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason cooper	jvcpainting88@gmail.com	Self	Stockton	IA	United States	Violet minssen	Hope Bishop	Signed
12	2019-12-17 19:54	Anonymous (not verified)	50.83.188.192	B & B Construction	Proprietorship	2463 93rd Avenue 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.	2019-12-17	Brock A Maxwell	brock246393@gmail.com	Des Moines	IA	United States	Hope Winegardner	Yvonne Ginther	Signed	(1) The employer does not elect the employers’ liability coverage.	Brock A Maxwell	brock246393@gmail.com	Owner	Des Moines	POlK	Iowa	Yvonne Ginther	Hope Winegardner	Signed
1250	2022-08-10 09:10	Anonymous (not verified)	75.162.190.54	Merit Paint Company	Proprietorship	1629 24th 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.	2022-08-10	James Edward Simpson	jaybirdsimpson40@aol.com	Des Moines	Polk	Iowa	Regan Simpson	Hudson Simpson	Signed	(1) The employer does not elect the employers’ liability coverage.	James Simpson	jaybirdsimpson40@aol.com	Owner	Des Moines	Polk	Iowa	Regan Simpson	Hudson Simpson	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
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
1583	2023-04-18 14:04	Anonymous (not verified)	94.188.205.166	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
1584	2023-04-18 14:04	Anonymous (not verified)	94.188.205.166	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
1585	2023-04-18 14:04	Anonymous (not verified)	94.188.205.167	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
674	2021-10-15 09:43	Anonymous (not verified)	173.29.63.3	Peter Hawley	Proprietorship	524 n galena ave, Wyoming Illinois 61491	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-15	Peter Anthony Hawley	hawleypete801@gmail.com	Wyoming	Stark	Illinois	Elizabeth Doreen Hawley	Ian Matthew Esmoil	Signed	(1) The employer does not elect the employers’ liability coverage.	Peter Anthony Hawley	hawleypete801@gmail.com	Self	Wyoming	Stark	IL	Elizabeth Doreen Hawley	Ian Matthew Esmoil	Signed
437	2021-03-16 18:31	Anonymous (not verified)	38.121.121.16	Thompsen Irrigation	Proprietorship	16086 Missouri Ave Crescent IA 51526	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-17	James R Thompsen	jthom76285@aol.com	Crescent	Pottawattamie	Iowa	Mike Harmon	Ilene Harmon	Signed	(1) The employer does not elect the employers’ liability coverage.	James R Thompsen	jthom76285@aol.com	self	Crescent	Pottawattamie	Iowa	Mike Harmon	Ilene Harmon	Signed
1750	2023-07-17 11:00	Anonymous (not verified)	94.188.205.166	Mario Flores	Proprietorship	2101 E Virginia Ave. Apt 1 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.	2021-07-22	Mario Zubia Flores	deb@piciowa.com	Des Moiines	Polk	Iowa	Inspro employee 2022	Inspro employee 2022	Signed	(1) The employer does not elect the employers’ liability coverage.	Mario Zubia Flores	deb@piciowa.com	self	Des Moines	Polk	Iowa	Inspro employee 2022	Inspro employee 2022	Signed
1751	2023-07-17 11:00	Anonymous (not verified)	94.188.205.166	Mario Flores	Proprietorship	2101 E Virginia Ave. Apt 1 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.	2021-07-22	Mario Zubia Flores	deb@piciowa.com	Des Moiines	Polk	Iowa	Inspro employee 2022	Inspro employee 2022	Signed	(1) The employer does not elect the employers’ liability coverage.	Mario Zubia Flores	deb@piciowa.com	self	Des Moines	Polk	Iowa	Inspro employee 2022	Inspro employee 2022	Signed
1749	2023-07-17 10:52	Anonymous (not verified)	94.188.205.175	Zenon Loreto	Proprietorship	1324 E 29th 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.	2021-07-17	Zenon Loreto	deb@piciowa.com	Des Moines	Polk	Iowa	Inspro in 2019	Inspro in 2019	Signed	(1) The employer does not elect the employers’ liability coverage.	Zenon Loreto	deb@piciowa.com	self	Des Moines	Polk	Iowa	Inspro in 2019	Inspro in 2019	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
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
105	2020-03-27 12:15	Anonymous (not verified)	174.219.134.4	Elijah Willier	Proprietorship	805 SE 15th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-27	Elijah Willier	e.willier42798@gmail.com	Grimes	Polk	IA	Isaac Willier	Isaiah Willier	Signed	(1) The employer does not elect the employers’ liability coverage.	Elijah Willier	e.willier42798@gmail.com	Self/ sole proprietor	Grimes	Polk	IA	Isaac Willier	Isaiah Willier	Signed
385	2021-02-07 12:43	Anonymous (not verified)	173.17.12.148	H@E roofing LLC	Limited Liability Company	1912 Burson street Des Moines is 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.	2020-06-04	Heather Hickman	hratherhickman@gmail.com	Des moines	Polk	Iowa	Jerry freeborn	Ivan torres	Signed	(1) The employer does not elect the employers’ liability coverage.	Heather Hickman	hratherhickman@gmail.com	Self	Des moines	Polk	Iowa	Jerry freeborn	Ivan torres	Signed
1308	2022-09-14 21:25	Anonymous (not verified)	166.196.110.63	Anhalt Trucking	Limited Liability Company	Canby MN	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-13	Jordan J Anhalt	anhalt.trucking@gmail.com	Canby	MN	United States	Ashley Anhalt	Jace Anhalt	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan J Anhalt	anhalt.trucking@gmail.com	Same	Canby	MN	United States	Ashley Anhalt	Jace Anhalt	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
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
1135	2022-05-31 12:06	Anonymous (not verified)	174.215.227.133	Plagman Transportation	Limited Liability Company	1306 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.	2022-05-31	Ryan Plagman	rplagman@gmail.com	Adel	Dallas	Ia	Chris Christensen	Jack Ruby	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Plagman	rplagman@gmail.com	Same	Adel	Dallas	Ia	Chris Christensen	Jack Ruby	Signed
1937	2023-12-04 17:42	Anonymous (not verified)	94.188.205.174	Albert Schwartz	Proprietorship	2250 Hwy 1 Sw Kalona, ia 52247	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-04	Albert Schwartz	sageburnner100@msn.com	Kalona	Johnson	Iowa	Laura Schwartz	Jackie Etheredge	Signed	(1) The employer does not elect the employers’ liability coverage.	Albert Schwartz	sageburnner100@msn.com	Myself	Kalona	Johnson	Iowa	Laura Schwartz	Jackie Etheredge	Signed
1345	2022-10-25 15:25	Anonymous (not verified)	166.181.82.169	Estling Junk and Garbage Removal	Limited Liability Company	660 West Main Street Apt.5	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-10-25	Jacob Steven Estling	JacobEstling1@gmail.com	Maynard	Fayette	Iowa	Jacob Estling	Jacob Estling	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jacob Steven Estling	jacobestling1@gmail.com	Owner	Maynard	Fayette	Iowa	Jacob Estling	Jacob Estling	Signed
1121	2022-05-19 17:45	Anonymous (not verified)	107.115.239.35	KG Land works LLC	Limited Liability Company	P.O. Box 931Barnsdall Oklahoma 74002	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-19	Keiven Brooke Slone	keiven.slone@gmail.com	Barnsdalll	Osage	OK	Colton Kelley	Dalton Gardner	Signed	(1) The employer does not elect the employers’ liability coverage.	Colton Kelley	kglandworks@gmail.com	Owner	Barnsdalll	Osage	OK	Dalton Garder	Jacob Kelley	Signed
2013	2024-01-31 15:14	Anonymous (not verified)	94.188.205.167	Aspen Ridge LLC	Limited Liability Company	1404 G Ave Marengo, IA 52301	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-10	Jeffrey McKusker	jeff@mckuskerelectric.com	Marengo	Iowa	Iowa	Karly Kovar	Jacob McKusker	Signed	(1) The employer does not elect the employers’ liability coverage.	Lori McKusker	jeff@mckuskerelectric.com	Spouse	Mead	Weld	Colorado	Karly Kovar	Jacob McKusker	Signed
2014	2024-01-31 15:17	Anonymous (not verified)	94.188.205.174	Aspen Ridge LLC	Limited Liability Company	1404 G 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.	2023-05-10	Lori McKusker	lori@mckuskerelectric.com	Mead	Weld	Colorado	Karly Kovar	Jacob McKusker	Signed	(1) The employer does not elect the employers’ liability coverage.	Lori McKusker	jeff@mckuskerelectric.com	Self	Mead	Weld	Colorado	Karly Kovar	Jacob McKusker	Signed
579	2021-07-20 12:37	Anonymous (not verified)	166.205.124.133	M&M HOME IMPROVEMENT	Limited Liability Company	5406 28th Ave. Moline , IL 61265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-07-20	Jarred Alexander	bookkyddjay@gmail.com	Moline	USA	IL	Jacob Nagel	Jacob Nagel	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jarred Alexander	bookkyddjay@gmail.com	Same	Moline	USA	IL	Jacob Nagel	Jacob Nagel	Signed
1325	2022-10-02 20:07	Anonymous (not verified)	50.80.107.101	Hanson Custom Cleanup and Removal LLC	Limited Liability Company	1221 Fleur Dr. 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.	2022-10-02	Jason Jacob Hanson	jasonhanson1985@gmail.com	Waterloo	Blackhawk	Iowa	Cindy Shreve	Jacob Ring	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Hanson	jasonhanson1985@gmail.com	Self	Waterloo	Blackhawk	Iowa	Cindy Shreve	Jacob Ring	Signed
993	2022-03-22 10:36	Anonymous (not verified)	173.18.6.21	Clay Winkelmann	Proprietorship	1652 227th Street, Fontanelle, IA 50846	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-22	Clay Winkelmann	crwwproperties@gmail.com	Fontanelle	Adair	Iowa	Kathryn Larson	Jacob Tiernan	Signed	(1) The employer does not elect the employers’ liability coverage.	Clay Winkelmann	crwwproperties@gmail.com	Owner	Fontanelle	Adair	Iowa	Kathryn Larson	Jacob Tiernan	Signed
1009	2022-03-28 07:24	Anonymous (not verified)	173.18.6.21	Clay Windelmann	Limited Liability Company	362 Public Square, Greenfield, IA 50849	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	C;ay Winkelman	crwwproperties@gmail.com	Fontanelle	Adair	Iowa	Kathryn Larson	Jacob Tiernan	Signed	(1) The employer does not elect the employers’ liability coverage.	Clay Winkelmann	crwwproperties@gmail.com	Owner/Self	Fontanelle	Adair	Iowa	Kathryn Larson	Jacob Tiernanq	Signed
1795	2023-08-11 08:02	Anonymous (not verified)	94.188.205.176	Overall Cleaning	Proprietorship	507 Enterprise Ct #6 Independence IA 50644	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-11	Michelle L. Vonsprecken	michelle.vonsprecken@gmail.com	Independence	Buchanan	Iowa	Jacob Von Sprecken	Cody Caraway	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin C Hayes	overallcleaning21@gmail.com	Business Partner	Marion	Linn	IA	Cody Caraway	Jacob Von Sprecken	Signed
2026	2024-02-07 08:32	Anonymous (not verified)	94.188.205.169	Strong Fencing & Decking LLC	Limited Liability Company	343 59th Street 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.	2024-02-07	Jacob James Strong	strongfencingdecking@gmail.com	Des Moines	Polk	Iowa	Paige Crowley	Jacob Waugh	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob Strong	strongfencingdecking@gmail.com	Owner	Des Moines	Polk	Iowa	Paige Crowley	Jacob Waugh	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
1419	2023-01-12 09:27	Anonymous (not verified)	71.34.173.44	Solid Solutions Caulking LLC.	Limited Liability Company	1011 N. Ankeny BLVD Po 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.	2023-01-01	Jesse Guilford	sscaulking@yahoo.com	Ankeny	Polk	Iowa	Jesse Guilford	Jade Guilford	Signed	(1) The employer does not elect the employers’ liability coverage.	Jesse Guilford	sscaulking@yahoo.com	Self	Ankeny	Polk	Iowa	Jesse Guilford	Jade Guilford	Signed
1349	2022-10-28 12:37	Anonymous (not verified)	173.26.153.59	spotlight drywall	Proprietorship	1001 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.	2022-06-01	paul woods	spotlight.2008@hotmail.com	Grundy Center	Ia	United States	thuy do	jaden do	Signed	(1) The employer does not elect the employers’ liability coverage.	thuy do	spotlight.2008@hotmail.com	bookeeper	Grundy Center	Ia	United States	thuy do	jaden do	Signed
854	2022-01-24 19:59	Anonymous (not verified)	217.180.228.216	Hansen Installations	Limited Liability Company	109 NW Calista 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.	2022-01-24	Brian D Hansen	bdhansen33@gmail.com	Grimes	IA	United States	Laurie Mills	Jaiden Nelson	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian D Hansen	bdhansen33@gmail.com	Self	Grimes	IA	United States	Laurie Mills	Jaiden Nelson	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
573	2021-07-14 09:12	Anonymous (not verified)	166.181.83.201	Dustin Demoss	Proprietorship	407 mechanic 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.	2021-07-13	Dustin Michael DeMoss	dustindemoss14@gmail.com	Monmouth	Iowa	United States	Jake	Jake	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin Michael DeMoss	dustindemoss14@gmail.com	Idk	Monmouth	Iowa	United States	Jake	Jake	Signed
207	2020-07-16 13:05	Anonymous (not verified)	173.16.140.254	Steve Kennedy	Proprietorship	5108 SW 13th 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.	2020-07-16	Steve Kennedy	stevekennedy@gmail.com	Des Moines	Polk	Iowa	Jen Echterling	Jake Hibbert	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Kennedy	stevekennedy007@gmail.com	Owner	Des Moines	Polk	Iowa	Jen Echterling	Jake Hibbert	Signed
253	2020-09-09 12:27	Anonymous (not verified)	173.18.16.129	H E Drywall INC	Proprietorship	200 E Lally 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.	2020-09-09	Eriberto Castro	hedrywall82@gmail.com	Des Moines	Polk	Iowa	Lesa Reeves	Jake Hibbert	Signed	(1) The employer does not elect the employers’ liability coverage.	eriberto castro	hedrywall82@gmail.com	owner	Des Moines	Polk	Iowa	Lesa Reeves	Jake Hibbert	Signed
1950	2023-12-12 12:20	Anonymous (not verified)	94.188.205.168	Central Iowa Welding & Repair	Limited Liability Company	13913 140th 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.	2023-01-01	Trevor Campbell	centraliowaweldingrepair@gmail.com	Indianola	Warren	Iowa	Amber Campbell	Jake Snow	Signed	(1) The employer does not elect the employers’ liability coverage.	Trevor Campbell	centraliowaweldingrepair@gmail.com	Owner	Indianola	Warren	Iowa	Amber Campbell	Jake Snow	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
2173	2024-04-23 14:19	Anonymous (not verified)	94.188.205.166	Duer and Sons Remodeling, Inc	Partnership	1795 Se 82nd St, Runnells Iowa 50237	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Duer	John@duerandsonsremodeling.com	Runnells	Polk	Iowa	Travis Justice	Jake VanGorp	Signed	(1) The employer does not elect the employers’ liability coverage.	John Duer	John@duerandsonsremodeling.com	Owner	Runnells	Polk	Iowa	Travis Justice	Jake VanGorp	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
15	2019-12-30 18:13	Anonymous (not verified)	104.166.243.52	Matt Moore	Proprietorship	8450 Hickman Road #15C	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-12-30	Matt Moore	mljm2016@outlook.com	Clive	Iowa	Iowa	Tom Onnen	James Buffington	Signed	(1) The employer does not elect the employers’ liability coverage.	Matt Moore	mljm2016@outlook.com	Subcontractor	Urbandale	IOWA	United States	Tom Onnen	James Buffington	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
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
1222	2022-07-21 16:01	Anonymous (not verified)	66.129.208.246	James J Stallman	Proprietorship	190 BLUFF DR, Fairfax, IA 52228	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	James J Stallman	stallmanjim@aol.com	FAIRFAX	IA	United States	James J Stallman	James J Stallman	Signed	(1) The employer does not elect the employers’ liability coverage.	Lundahl, Hatt, Austad Tax Services Inc	NN@LHAtax.com	President	Marion	Linn	IA	James J Stallman	James J Stallman	Signed
1572	2023-04-13 11:12	Anonymous (not verified)	94.188.205.167	CK Trucking	Proprietorship	24497 Hayes Street, Pleasantville, Iowa 50225	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-13	Craig Kooyman	dmsstumpguy@yahoo.com	Pleasantville	IA	IA	Chad Randleman	James Jordan	Signed	(1) The employer does not elect the employers’ liability coverage.	Craig Kooyman	dmsstumpguy@yahoo.com	Owner	Pleasantville	Warren	IA	Chad Randleman	James Jordan	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
680	2021-10-18 13:58	Anonymous (not verified)	166.181.86.88	Gerald Jerome	Proprietorship	2668 Wapsi Ridge Dr. Walker, IA 52352	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-18	Gerald Jerome	geraldjerome373@ymail.com	Walker	IA	United States	Benjamin J Barkalow	James M. Barkalow	Signed	(1) The employer does not elect the employers’ liability coverage.	Gerald Jerome	geraldjerome373@ymail.com	Self employed	Walker	Linn	Iowa	Benjamin J Barkalow	James M Barkalow	Signed
296	2020-10-29 09:39	Anonymous (not verified)	174.243.81.9	Alex Vanderbeek	Proprietorship	85 NE Grace Wood Drive, Waukee, Iowa 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-29	Alex Vanderbeek	Vanderbeek17151@gmail.com	Waukee	Dallas	Iowa	Joe Simpson	James Nelson	Signed	(1) The employer does not elect the employers’ liability coverage.	Alex Vanderbeek	Vanderbeek17151@gmail.com	self	WAUKEE	IA	United States	Joe Simpson	James Nelson	Signed
302	2020-10-31 13:04	Anonymous (not verified)	173.17.230.149	Absolute Construction	Partnership	3720 Patricia Drive, 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.	2020-10-31	Joe Simpson	jrsimpson27@gmail.com	Urbandale	Polk	Iowa	Alex Vanderbeek	James Nelson	Signed	(1) The employer does not elect the employers’ liability coverage.	Joe Simpson	jrsimpson27@gmail.com	self	Urbandale	Polk	Iowa	Alex Vanderbeek	James Nelson	Signed
304	2020-10-31 13:23	Anonymous (not verified)	173.17.230.149	Jerome Jones	Proprietorship	5203 Douglas Avenue, 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.	2020-10-31	Jerome Jones	jeromepops1@gmail.com	Des Moines	Polk	IA	Joe Simpson	James Nelson	Signed	(1) The employer does not elect the employers’ liability coverage.	Jerome Jones	jeromepops1@gmail.com	self	Des Moines	Polk	IA	Joe Simpson	James Nelson	Signed
1188	2022-07-07 11:24	Anonymous (not verified)	107.117.176.70	Pitts Aerial Services LLC	Limited Liability Company	2478 county road 1488 Cullman al 35058	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-07	Austin Branch Pitts	pittsaerial@gmail.com	Cullman	Cullman	AL	Sydney Pitts	James Robertson	Signed	(1) The employer does not elect the employers’ liability coverage.	Austin Branch Pitts	pittsaerial@gmail.com	Owner	Cullman	Cullman	AL	Sydney Pitts	James Robertson	Signed
1189	2022-07-07 11:50	Anonymous (not verified)	71.91.55.59	Austin Branch Pitts	Proprietorship	2478 county road 1488 Cullman al 35058	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-07	Austin Branch Pitts	pittsaerial@gmail.com	Cullman	Cullman	AL	Sydney Pitts	James Robertson	Signed	(1) The employer does not elect the employers’ liability coverage.	Austin Branch Pitts	pittsaerial@gmail.com	Proprietor	Cullman	Cullman	AL	Sydney Pitts	James Robertson	Signed
1210	2022-07-18 08:15	Anonymous (not verified)	173.22.187.234	Cardinal Rule Handyman Services, LLC	Limited Liability Company	1304 E 10th St S, Newton, IA 50208	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-18	James Andrew Dunlap	cardinarulehandyman@gmail.com	Newton	Jasper	Iowa	Jacinda Marie Dunlap	James Thornton Dunlap	Signed	(1) The employer does not elect the employers’ liability coverage.	James Andrew Dunlap	cardinalrulehandyman@gmail.com	I am the authorized agent	Newton	Jasper	Iowa	Jacinda Marie Dunlap	James Thornton Dunlap	Signed
58	2020-02-10 21:18	Anonymous (not verified)	75.162.11.63	Moni tile Services llc	Limited Liability Company	2207 E Walnut 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.	2020-02-01	Monica M Sandoval	Mjsandoval20@yahoo.com	Des Moines	Polk	United States	Cassie Ann bentz	James wesley harkert	Signed	(1) The employer does not elect the employers’ liability coverage.	Moni tile services llc	Mjsandoval20@yahoo.com	Self	Des Moines	Polk	Iowa	Cassie Ann bentz	James wesley harkert	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
413	2021-02-24 16:21	Anonymous (not verified)	199.120.93.40	Nelson Tire Recycling LLC	Limited Liability Company	2270 Farley Rd Cascade Iowa 52033	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-02-24	Richard A Nelson	nelsontirerecycling@gmail.com	Cascade	Dubugue	Iowa	Wendy Bergfeld	Jan Elhinger	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Richard	nelsontirerecycling@gmail.com	Owner/officer	Cascade	Dubugue	Iowa	Wendy Bergfeld	Jan Ehlinger	Signed
952	2022-03-05 18:23	Anonymous (not verified)	108.59.100.21	Heaven Sent PC LLC	Limited Liability Company	604 Allamakee St, Waukon,IA 52172	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-01	Justin Piggott	heavensentpetcremation@gmail.com	Waukon	Allamakee	Iowa	Kaia Piggott	Jane M Regan	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Piggott	heavensentpetcremation@gmail.com	Member of LLC	Waukon	Allamakee	Iowa	Kaia Piggott	Jane M Regan	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
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
855	2022-01-26 10:39	Anonymous (not verified)	209.152.66.250	Robert L Stutzman	Limited Liability Company	33784 Hwy 22	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-26	Robert L Stutzman	bnbstutzman@gmail.com	Keota	Iowa	United States	Dasha Hesseltine	Janette Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Sandra Stutzman	iafarmgirl90@gmail.com	Daughter	Keota	Iowa	United States	Dasha Hesseltine	Janette Miller	Signed
461	2021-04-06 08:49	Anonymous (not verified)	209.152.77.101	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln ST., Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-06	Bart Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed	(1) The employer does not elect the employers’ liability coverage.	Bart Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed
462	2021-04-06 08:56	Anonymous (not verified)	209.152.77.101	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln ST., Ruthven,IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-06	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
975	2022-03-15 10:34	Anonymous (not verified)	209.152.77.101	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln ST., Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-15	Bart Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed	(1) The employer does not elect the employers’ liability coverage.	Bart Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed
976	2022-03-15 10:44	Anonymous (not verified)	209.152.77.101	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln ST., Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-15	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
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
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
2140	2024-04-09 09:28	Anonymous (not verified)	94.188.205.175	Bart Fuller& James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln Street Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-09	Bart Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Kathryn Kelley	Janice Henningsen	Signed	(1) The employer does not elect the employers’ liability coverage.	Bart Fuller	goffins@ruthventel.com	Partner	Ruthven	PAlo Alto	Iowa	Kathryn Kelley	Janice Henningsen	Signed
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
2142	2024-04-09 09:39	Anonymous (not verified)	94.188.205.167	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	Pal 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
978	2022-03-15 12:42	Anonymous (not verified)	173.24.17.213	Jose Antonio Hernández Tobar	Limited Liability Company	219 Huisman 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.	2022-03-15	Jose Antonio Hernandez Tobar	josehernanr5@icloud.com	Marshalltown	Marshall	Iowa	Cindy Garcia Hernandez	Jaquelin Garcia Barajas	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Antonio Hernandez Tobar	josehernanr5@icloud.com	Self	Marshalltown	Marshall	Iowa	Cindy Garcia Hernandez	Jaquelin Garcia Barajas	Signed
466	2021-04-08 09:58	Anonymous (not verified)	216.81.153.249	Supreme Express Transport LLC	Limited Liability Company	609 Euclid Ave, Cherokee, IA 51012	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-10	Liana Gil	liana2702@gmail.com	Cherokee	Cherokee	Iowa	Leigh Laven	Jared Brashears	Signed	(1) The employer does not elect the employers’ liability coverage.	Liana Gill	liana2702@gmail.com	Owner	Cherokee	Cherokee	Iowa	Leigh Laven	Jared Brashears	Signed
1576	2023-04-17 08:32	Anonymous (not verified)	94.188.205.167	Reece Wilson	Limited Liability Company	1431 Starbeck Circle	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-14	Reece J Wilson	rjwilson030@gmail.com	Cedar Falls	Blackhawk	Iowa	Kendall Cotant	Darryl Mason	Signed	(1) The employer does not elect the employers’ liability coverage.	John Richter	jrichter@beecherlaw.com	Business	Waterloo	Blackhawk	Iowa	Kendall Cotant	Jared Hottle	Signed
966	2022-03-11 10:04	Anonymous (not verified)	173.19.189.168	Steger Siding & Construction	Limited Liability Company	1020 25th 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.	2022-03-11	Jared Steger	jared.steger@gmail.com	Marion	IA	United States	Jared Steger	Jared Steger	Signed	(1) The employer does not elect the employers’ liability coverage.	Jared Steger	jared.steger@gmail.com	self	Marion	IA	United States	Jared Steger	Jared Steger	Signed
1076	2022-04-28 13:14	Anonymous (not verified)	149.20.212.228	Van Ginkel Farms LLC	Limited Liability Company	2745 Chestnut Ave Inwood, IA 51240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-14	James Van Ginkel	bonnievanginkel@gmail.com	Inwood	Lyon	Iowa	Jesse Niemeyer	Jaslyn VanOtterloo	Signed	(1) The employer does not elect the employers’ liability coverage.	James VanGinkel	bonnievanginkel@gmail.com	self	Inwood	Lyon	Iowa	Jesse Niemeyer	Jaslyn VanOtterloo	Signed
1077	2022-04-28 13:16	Anonymous (not verified)	149.20.212.228	Van Ginkel Farms LLC	Limited Liability Company	2745 Chestnut Ave Inwood, IA 51240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-14	Bonnie VanGinkel	bonnievanginkel@gmail.com	Inwood	Lyon	Iowa	Jesse Niemeyer	Jaslyn VanOtterloo	Signed	(1) The employer does not elect the employers’ liability coverage.	James VanGinkel	bonnievanginkel@gmail.com	owner	Inwood	Lyon	Iowa	Jesse Niemeyer	Jaslyn VanOtterloo	Signed
1618	2023-04-28 11:10	Anonymous (not verified)	94.188.205.167	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	James Lynn Cary	hunterflying@att.net	Hunter	Woodruff	Arkansas	Karen Gifford	Jason White	Signed	(1) The employer does not elect the employers’ liability coverage.	James Lynn Cary	hunterflying@att.net	Self	Hunter	Woodruff	AR	Karen Gifford	Jason White	Signed
1246	2022-08-08 12:33	Anonymous (not verified)	174.215.249.59	Dustin Rambo	Proprietorship	4570, Hunter 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.	2022-08-07	Dustin Lee Rambo	dlrambo80@gmail.com	Palo	USA	IA	Matt Lytle	Jason Achenbach	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin Rambo	dlrambo80@gmail.com	Self	Palo	USA	IA	Matt Lytle	Jason Achenbach	Signed
365	2021-01-15 11:24	Anonymous (not verified)	63.227.74.126	Paramount Kitchen and Bath	Limited Liability Company	2155 SE 37TH ST STE C	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-15	Michael Simpson	mike@paramount-kitchens.com	GRIMES	Iowa	United States	Cory Morris	Jason Andersen	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Simpson	mike@paramount-kitchens.com	Owner	GRIMES	Iowa	United States	Cory Morris	Jason Andersen	Signed
584	2021-07-23 15:38	Anonymous (not verified)	75.162.41.54	Bradens Roofing & Construction LLc	Limited Liability Company	2450 Hart Ave, Des Moines, IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-23	Arsenio Vargas	avargas409@gmail.com	Des Moines	Polk	Iowa	Marc Black	Jason Anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Arsenio Vargas	avargas409@gmail.com	Owner	Des Moines	Polk	Iowa	Marc Black	Jason Anderson	Signed
2081	2024-03-08 10:44	Anonymous (not verified)	94.188.205.167	T & S Sandblasting and Painting LLC	Limited Liability Company	101 Clinton ST Corwith IA 50430	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Matthew Tindall	matt.tindall83@gmail.com	Corwith	Hancock	IA	Wendy S Jensen	Jason Bradley	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Tindall	matt.tindall83@gmail.com	self	Corwith	Hancock	IA	Wendy S Jensen	Jason Bradley	Signed
2082	2024-03-08 10:47	Anonymous (not verified)	94.188.205.176	T & S Sandblastin and Painting LLC	Limited Liability Company	101 Clinton ST Corwith IA 50430	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Robert Schissel	matt.tindall83@gmail.com	Corwith	Hancock	Iowa	Wendy S Jensen	Jason Bradley	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Schissel	matt.tindall83@gmail.com	self	Corwith	Hancock	Iowa	Wendy S Jensen	Jason Bradley	Signed
1015	2022-03-29 10:56	Anonymous (not verified)	129.255.1.117	Alli Center	Proprietorship	1150 5th St Suite 270 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.	2022-03-29	Miranda K Maday	miranda.maday@alli-center.com	North Liberty	Johnson	Iowa	Zara Wanlass	Jason Knight	Signed	(1) The employer does not elect the employers’ liability coverage.	Zara Wanlass	zara.wanlass@alli-center.com	Co-Owner and Business Manager	Iowa City	Johnson	IA	Miranda K Maday	Jason Knight	Signed
1194	2022-07-08 13:12	Anonymous (not verified)	174.45.15.103	307 Safety LLC	Limited Liability Company	9 Trinidad CT Gillette, WY 82716	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-08	Joshua Peter Tompkins	JTompkins@307Safety.com	Gillette	Campbell	Wyoming	Paul Prather	Jason Praus	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua Peter Tompkins	JTompkins@307Safety.com	Owner	Gillette	Campbell	Wyoming	Paul Prather	Jason Praus	Signed
1230	2022-07-27 08:59	Anonymous (not verified)	108.217.146.87	Hunter Flying Service	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.	2022-07-27	Lynn Cary	hunterflying@att.net	Hunter	Woodruff	United States	Karen Gifford	Jason White	Signed	(1) The employer does not elect the employers’ liability coverage.	Lynn Cary	hunterflying@att.net	Owner	Hunter	AR	United States	Karen Gifford	Jason White	Signed
1231	2022-07-27 11:59	Anonymous (not verified)	108.217.146.87	Adam Towe	Proprietorship	26 Reeves Rd Hartselle, AL 35640	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-27	Adam Towe	adamtowe99@gmail.com	Hartselle	Morgan	AL	Lynn Cary	Karen Gifford	Signed	(1) The employer does not elect the employers’ liability coverage.	Hunter Flying Service	hunterflying@att.net	Owner	Hunter	AR	United States	Karen Gifford	Jason White	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
407	2021-02-18 10:47	Anonymous (not verified)	165.225.61.119	Ryan Myers Painting	Proprietorship	836 25th St Rock Island, IL 61201	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-21	Ryan Myers	tickspoon@yahoo.com	Rock Island	Rock Island	IL	Seth Rowland	Jay Romeo	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Myers	tickspoon@yahoo.com	Self	Rock Island	Rock Island	IL	Seth Rowland	Jay Romeo	Signed
408	2021-02-18 10:51	Anonymous (not verified)	165.225.61.119	Brandon Anderson Painting	Proprietorship	608 30th St Rock Island, IL 61201	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-21	Brandon Anderson	banderson792@gmail.com	Rock Island	Rock Island	IL	Seth Rowland	Jay Romeo	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandon Anderson	banderson792@gmail.com	Self	Rock Island	Rock Island	IL	Seth Rowland	Jay Romeo	Signed
1611	2023-04-27 09:21	Anonymous (not verified)	94.188.205.168	powell express moving	Proprietorship	2600 Marquette Pl 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.	2023-04-27	Roger Powell	powellexpressmoving@gmail.com	Dubuque	Dubuque	Iowa	Connie Powell	Jay Weiser	Signed	(1) The employer does not elect the employers’ liability coverage.	Roger Powell	powellexpressmoving@gmail.com	Self	Dubuque	Dubuque	Iowa	Connie Powell	Jay Weiser	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
1209	2022-07-17 16:41	Anonymous (not verified)	166.181.86.161	JustbelieveCreationsllc	Limited Liability Company	104 East Chestnut 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.	2022-07-17	Joshua Riera-Gomez	josh.gomez.com@gmail.com	Garnavillo	IA	United States	Eric Jarman	Jean brandt	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua Riera-Gomez	josh.gomez.com@gmail.com	Myself	Garnavillo	IA	United States	Eric jarman	Jean brandt	Signed
816	2021-12-30 09:56	Anonymous (not verified)	174.199.83.133	Michael Fales	Proprietorship	1987 180th Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-30	Michael Lee Fales	Chubby__69@hotmail.com	Canby	Yellow Medicine	Minnesota	Tori Fales	Jean Fales	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Lee Fales	Chubby__69@hotmail.com	Owner	Canby	Yellow Medicine	Minnesota	Tori Fales	Jean Fales	Signed
1471	2023-02-20 10:24	Anonymous (not verified)	94.188.205.169	Vega Investments	Limited Liability Company	330 NE 72nd Street, Pleasant Hill, IA 50327	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-20	Stephanie Westrom	stephanie.westrom@microsoft.com	Pleasant Hill	Polk	Iowa	Thomas Westrom	Jean Schnake	Signed	(1) The employer does not elect the employers’ liability coverage.	Stephanie Westrom	stephanie.westrom@microsoft.com	Owner	Pleasant Hill	Polk	Iowa	Thomas Westrom	Jean Schnake	Signed
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
1107	2022-05-16 15:28	Anonymous (not verified)	64.33.230.163	hangar 8 spray service	Limited Liability Company	1626 airport dr	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-16	jed douglas hansen	hangar.8@hotmail.com	Clark	South Dakota	United States	jed douglas hansen	jed douglas hansen	Signed	(1) The employer does not elect the employers’ liability coverage.	jed douglas hansen	hangar.8@hotmail.com	contract	Clark	South Dakota	United States	Jed Hansen	Jed Hansen	Signed
1110	2022-05-17 11:17	Anonymous (not verified)	64.33.230.163	Jed Hansen	Proprietorship	1626 Airport Dr	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-17	Jed Douglas Hansen	hangar.8@hotmail.com	Clark	Clark	South Dakota	Jed Hansen	Jed Hansen	Signed	(1) The employer does not elect the employers’ liability coverage.	Jed Hansen	hangar.8@hotmail.com	Proprietor	Clark	Clark	South Dakota	Jed Hansen	Jed Hansen	Signed
1111	2022-05-17 11:18	Anonymous (not verified)	64.33.230.163	Jed Hansen	Proprietorship	1626 Airport Dr	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-17	Jed Douglas Hansen	hangar.8@hotmail.com	Clark	Clark	South Dakota	Jed Hansen	Jed Hansen	Signed	(1) The employer does not elect the employers’ liability coverage.	Jed Hansen	hangar.8@hotmail.com	Proprietor	Clark	Clark	South Dakota	Jed Hansen	Jed Hansen	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
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
529	2021-05-24 16:16	Anonymous (not verified)	67.230.239.111	Olsem Aerial Application Services LLC	Limited Liability Company	34538 County Road 13 Westbrook, Minnesota 56183	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-24	Benjamin Olsem	oaasllC@gmail.com	Westbrook	Cottonwood	Minnesota	Megan Olsem	Jeff Oberg	Signed	(1) The employer does not elect the employers’ liability coverage.	Olsem Aerial Application Services LLC	oaasllc@gmail.com	Owner/Self	Westbrook	Cottonwood	Minnesota	Megan Olsem	Jeff Oberg	Signed
859	2022-01-27 11:29	Anonymous (not verified)	204.155.61.217	JD Drywall	Proprietorship	503 9th Street Kalona, Iowa 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.	2022-01-27	John Duwa	johnduwa@outlook.com	Kalona	Washington	Iowa	Angela Stutzman	Jeff Spenner	Signed	(1) The employer does not elect the employers’ liability coverage.	JD Drywall - John Duwa	johnduwa@outlook.com	owner	Kalona	Washington	Iowa	Angela Stutzman	Jeff Spenner	Signed
1876	2023-10-23 14:26	Anonymous (not verified)	94.188.205.169	Magnus, LLC	Limited Liability Company	1120 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.	2023-10-23	Kristina Link	magnina@aol.com	Cedar Rapids	IA	IA	Shannon Thompson	Jeff Spies	Signed	(1) The employer does not elect the employers’ liability coverage.	Kristina Link	magnina@aol.com	business owner	Cedar Rapids	Iowa	Iowa	Shannon Thompson	Jeff Spies	Signed
926	2022-02-17 15:20	Anonymous (not verified)	166.181.83.68	Staley Trucking LLC	Limited Liability Company	1388 140th 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.	2022-02-17	Travis Staley	staleyracing121@gmail.com	Hampton	Franklin	IA	Tyler Staley	Jeff Staley	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Staley	staleyracing121@gmail.com	President	Hampton	Franklin	IA	Tyler Staley	Jeff Staley	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
815	2021-12-28 12:29	Anonymous (not verified)	173.29.239.122	Comtek, Inc.	Proprietorship	3702 NW 13th 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.	2021-12-28	Micheal D. Qualley	mqcomtek@gmail.com	ANKENY	IA	United States	Jacque Blackman	Jeffery Keipper	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacque Blackman	jblackman@grimesfinancialgroup.com	client	Grimes	Polk	Iowa	Jacque Blackman	Jeffery Keipper	Signed
1824	2023-08-29 16:20	Anonymous (not verified)	94.188.205.176	Miller Construction Siding & Windows, LLC	Limited Liability Company	3104 S.W. 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.	2023-08-29	SCOTT MICHAEL DORAU	SMD50021@GMAIL.COM	Ankeny	Polk	United States	Christopher Bohn	Jeffrey Bohn	Signed	(1) The employer does not elect the employers’ liability coverage.	SCOTT MICHAEL DORAU	SMD50021@GMAIL.COM	PRESIDENT	Ankeny	POLK	United States	CHRISTOPHER BOHN	JEFFREY BOHN	Signed
467	2021-04-10 12:21	Anonymous (not verified)	24.252.54.168	Dave and Nancy Preucil Inc.	Proprietorship	13585 Clearview 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.	2021-04-10	Domenico Zurini II	davesspeedwaydz@gmail.com	Council Bluffs	IA	United States	Irven Saar II	Jeffrey Hanke	Signed	(1) The employer does not elect the employers’ liability coverage.	Barbi Zurini	bzurini@gmail.com	Wife	Council Bluffs	IA	United States	Irven Saar II	Jeffrey Hanke	Signed
73	2020-02-21 13:44	Anonymous (not verified)	192.30.185.233	Viejos Masnry construction LLC	Limited Liability Company	1708 Villa Ave. Sioux City IA 51103	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-13	Oscar Castro Ramirez	veijosconstruction@gmail.com	Sioux City	Woodbury	Iowa	JEFFREY H MCCLINTOCK	Nancy Fleming	Signed	(1) The employer does not elect the employers’ liability coverage.	Viejos Masonry Construction LLC	veijosconstruction@gmail.com	Owner/President	SIOUX CITY	Woodbury	Iowa	Nancy Fleming	Jeffrey Hugh McClintock	Signed
1129	2022-05-26 13:34	Anonymous (not verified)	172.58.227.18	Jonathan M Ramirez	Proprietorship	834 20th STREET SE. Cedar Rapids IA 53403	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-26	Jonathan M Ramirez	jon.hodgecma@gmail.com	Cedar Rapids	Linn	IA	Audrey Randle-EL	Jeffrey M Ramirez Jr.	Signed	(1) The employer does not elect the employers’ liability coverage.	Jonathan Ramirez	linncountyramirez@gmail.com	Owner	Cedar Rapids	Linn	Iowa	Audrey Randle-EL	Jeffrey Ramirez Jr	Signed
1130	2022-05-26 13:34	Anonymous (not verified)	172.58.227.18	Jonathan M Ramirez	Proprietorship	834 20th STREET SE. Cedar Rapids IA 53403	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-26	Jonathan M Ramirez	jon.hodgecma@gmail.com	Cedar Rapids	Linn	IA	Audrey Randle-EL	Jeffrey M Ramirez Jr.	Signed	(1) The employer does not elect the employers’ liability coverage.	Jonathan Ramirez	linncountyramirez@gmail.com	Owner	Cedar Rapids	Linn	Iowa	Audrey Randle-EL	Jeffrey Ramirez Jr	Signed
335	2020-12-08 11:08	Anonymous (not verified)	173.18.16.129	quintanillas construction llc	Limited Liability Company	3136 6th ave 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.	2020-12-08	maynor quintanilla	maynorquintanilla42@gmail.com	des moines	polk	Iowa	Lesa Reeves	Jen Lambert	Signed	(1) The employer does not elect the employers’ liability coverage.	maynor quintanilla	maynorquintanilla42@gmail.com	owner	des moines	polk	Iowa	Lesa Reeves	Jen Lambert	Signed
494	2021-04-22 12:41	Anonymous (not verified)	173.18.16.129	Unique Drywall Finishing LLC	Limited Liability Company	509 E 26th 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.	2021-04-22	jose angel chavez	uniquewal@yahoo.com	Des Moines	Polk	Iowa	Lesa Reeves	Jen Lambert	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Angel Chavez	uniquewal@yahoo.com	owner	Des Moines	Polk	Iowa	Lesa Reeves	Jen Lambert	Signed
1287	2022-08-30 13:11	Anonymous (not verified)	173.18.22.217	Gomez Painting	Limited Liability Company	3609 56th 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.	2022-08-30	Orlyn Gomez	orlyngomez9@gmail.com	Des Moines	Polk	Iowa	Lesa Reeves	Jen Lambert	Signed	(1) The employer does not elect the employers’ liability coverage.	Orlyn Gomez	orlyngomez9@gmail.com	Owner	Des Moines	Polk	Iowa	Lesa Reeves	Jen Lambert	Signed
291	2020-10-25 11:06	Anonymous (not verified)	208.126.69.94	self-employed	Proprietorship	PO Box 15, 430 E. Iowa 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.	2022-10-25	Steven Fisher	fishersjk@gmail.com	St. Mary's	Iowa	United States	Jodi Fisher	Jenna Fisher	Signed	(1) The employer does not elect the employers’ liability coverage.	Steven Fisher	fishersjk@gmail.com	same person	St. Mary's	Iowa	United States	Jodi Fisher	Jenna Fisher	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
2004	2024-01-28 12:41	Anonymous (not verified)	94.188.205.174	Wasabi Urbandale 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.	2024-01-28	Yean Ching Sue	soamie@hotmail.com	Urbandale	Dallas	Iowa	Lina Zheng	Jenna Yu	Signed	(1) The employer does not elect the employers’ liability coverage.	Yean Ching Sue	soamie@hotmail.com	Owner	Urbandale	Dallas	Iowa	Lina Zheng	Jenna Yu	Signed
403	2021-02-16 11:20	Anonymous (not verified)	192.30.185.142	Rodrigo Ochoa	Proprietorship	3310 5th St, 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.	2021-02-16	Rodrigo Ochoa	jesusochoa1976@icloud.com	Sioux City	Woodbury	IA	Katie Jenks	Jenni Ebner	Signed	(1) The employer does not elect the employers’ liability coverage.	Rodrigo Ochoa	jesusochoa1976@icloud.com	Owner	Sioux City	Woodbury	IA	Katie Jenks	Jenni Ebner	Signed
453	2021-03-26 08:27	Anonymous (not verified)	192.30.185.142	DYAD LLC	Partnership	2308 Summit St, Sioux City, IA 51104	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-26	Andrew Glisar	john@kellyconstruction.com	Sioux City	Woodbury	IA	Katie Jenks	Jenni Ebner	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Glisar	john@kellyconstruction.com	Owner/Partner	Sioux City	Woodbury	IA	Katie Jenks	Jenni Ebner	Signed
382	2021-02-02 13:19	Anonymous (not verified)	192.30.185.142	Double D Weatherization	Proprietorship	2069 Glenn Ellen Rd, Sergeant Bluff, IA 51054	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-02	Dale Gernhart	lakehome@longlines.com	Sergeant Bluff	Woodbury	IA	Nate Blaeser	Jenni Ebner	Signed	(1) The employer does not elect the employers’ liability coverage.	Dale Gerhart	lakehome@longlines.com	Self	Sergeant Bluff	Woodbury	IA	Nate Blaeser	Jennie Ebner	Signed
808	2021-12-20 12:28	Anonymous (not verified)	107.77.209.143	Painting & Design	Proprietorship	2728 51st 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.	2021-12-20	John Eugene Herman	jherman30@yahoo.com	Des moines	Polk	Iowa	Peggy Noplos	Jennifer Herman	Signed	(1) The employer does not elect the employers’ liability coverage.	John Herman	jherman30@yahoo.com	Self	Des moines	Polk	Iowa	Peggy Noplos	Jennifer Herman	Signed
498	2021-04-27 12:54	Anonymous (not verified)	173.31.147.225	TYREL KINKADE DBA: KINKADE CONSTRUCTION	Proprietorship	2289 165TH ST UNIT 10D	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-21	TYREL KINKADE	hogtyd97@yahoo.com	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	TYREL KINKADE	JOEL@WALKERINSURANCEIA.COM	SELF	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
512	2021-05-11 13:12	Anonymous (not verified)	173.31.147.225	RUTHVEN ROCKS LLC	Limited Liability Company	1205 ROLLING ST RUTHVEN IOWA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-11	JEFF CACEK	JEFF@RUTHVENROCKS.COM	RUTHVEN	PALO ALTO	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	JEFF CACEK	joel@walkerinsuranceia.com	MEMBER	RUTHVEN	PALO ALTO	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
513	2021-05-11 13:14	Anonymous (not verified)	173.31.147.225	RUTHVEN ROCKS LLC	Limited Liability Company	1205 ROLLING ST RUTHVEN IOWA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-11	KEITH CACEK	KEITH@RUTHVENROCKS.COM	RUTHVEN	PALO ALTO	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	KEITH CACEK	joel@walkerinsuranceia.com	MEMBER	RUTHVEN	PALO ALTO	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
514	2021-05-11 13:16	Anonymous (not verified)	173.31.147.225	RUTHVEN ROCKS LLC	Limited Liability Company	1205 ROLLING ST RUTHVEN IOWA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-11	MATT CACEK	MATT@RUTHVENROCKS.COM	MILFORD	DICKINSON	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	MATT CACEK	joel@walkerinsuranceia.com	MEMBER	MILFORD	PALO ALTO	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
670	2021-10-13 12:30	Anonymous (not verified)	173.19.179.111	MULLER TRANSPORT LLC	Limited Liability Company	2083 260TH 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.	2021-10-13	PAUL MULLER	MULLERTANSPORTLLC@GMAIL.COM	MILFORD	DICKINSON	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	PAUL MULLER	JOEL@WALKERINSURANCEIA.COM	SELF	MILFORD	DICKINSON	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1040	2022-04-12 09:36	Anonymous (not verified)	173.31.148.43	PAPA'S SMOKIN MEAT	Proprietorship	1940 147TH 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.	2022-04-12	KEITH MORISTON	PAPASSMOKINMEAT@GMAIL.COM	MONTGOMERY	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	KEITH MORISTON	PAPASSMOKINMEAT@GMAIL.COM	SELF	MONTGOMERY	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1041	2022-04-12 09:39	Anonymous (not verified)	173.31.148.43	PAPA'S SMOKIN MEAT	Proprietorship	1940 147TH 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.	2022-04-12	ROXANNE MORISTON	MORISTON2@YAHOO.COM	MONTGOMERY	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	ROXANNE MORISTON	MORISTON2@YAHOO.COM	SELF	MONTGOMERY	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1136	2022-05-31 13:46	Anonymous (not verified)	173.31.148.43	OKOBOJI BURRITO COMPANY LLC	Limited Liability Company	39502 710TH ST LAKEFIELD, MN 56105	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-26	KATHRYN SCHULTZ	kathrynlucier@ymail.com	LAKEFIELD	JACKSON	MN	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	KATHRYN SCHULTZ	kathrynlucier@ymail.com	SELF	LAKEFIELD	JACKSON	MN	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
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
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
1476	2023-02-22 12:23	Anonymous (not verified)	94.188.205.174	KARL INGWERSEN	Proprietorship	2716 FRANCIS SITES DR SPIRIT LAKE, IA 51360	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-22	KARL INGWERSEN	KARL58INGWERSEN@GMAIL.COM	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	KARL INGWERSEN	KARL58INGWERSEN@GMAIL.COM	SELF	SPIRIT LAKE	DICKSINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1498	2023-03-07 11:20	Anonymous (not verified)	94.188.205.176	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.	2023-02-20	MIKE KLEIN	joel@walkerinsuranceia.com	SIOUX FALLS	MINNEHAHA	SD	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	MIKE KLEIN	JOEL@WALKERINSURANCEIA.COM	SELF	SIOUX FALLS	MINNEHAHA	SD	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	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
1626	2023-05-05 11:16	Anonymous (not verified)	94.188.205.166	I HAWK BUILDERS LLC	Limited Liability Company	1417 INDIAN HILLS DR SPIRIT LAKE, IA 51360	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-05	BEN BRANT	babrant99@yahoo.com	SPIRIT LAKE	DICKINSON	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	BEN BRANT	joel@walkerinsuranceia.com	SELF	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1790	2023-08-08 14:32	Anonymous (not verified)	94.188.205.166	NJ CONSTRUCTION LLC	Limited Liability Company	4291 30TH AVE PETERSON, IA 51047	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	NICHOLAS JAMES JONES	njconstruction2014@hotmail.com	PETERSON	BUENA VISTA	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	NICHOLAS JAMES JONES	njconstruction2014@hotmail.com	SELF	PETERSON	BUENA VISTA	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	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
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
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
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
1894	2023-11-03 10:02	Anonymous (not verified)	94.188.205.167	ASHLEY QUAIL DBA: RUSTIC ROOTS SALON	Proprietorship	33596 SCHANY DR, RUTHVEN, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-03	ASHLEY QUAIL	ashley-mazzanti@hotmail.com	RUTHVEN	PALO ALTO	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	ASHLEY QUAIL	ashley-mazzanti@hotmail.com	SELF	RUTHVEN	PALO ALTO	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1941	2023-12-06 11:52	Anonymous (not verified)	94.188.205.167	GUEVARA CONCRETE LLC	Limited Liability Company	26 WESTVIEW DR APT 5 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.	2023-12-06	SAUL GUEVARA MEZA	ESMEJ2513@GMAIL.COM	MILFORD	DICKINSON	IA	TAMI SUE KLEIN	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	SAUL GUEVARA MEZA	ESMEJ2513@GMAIL.COM	SELF	MILFORD	DICKINSON	IA	TAMI SUE KLEIN	JENNIFER JANET YOUNGWIRTH	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
1978	2024-01-08 13:28	Anonymous (not verified)	94.188.205.167	TYREL GIBSON	Proprietorship	2004 CHICAGO AVE 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.	2024-01-08	TYREL GIBSON	TY11TEKFALL@GMAIL.COM	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	TYREL GIBSON	TY11TEKFALL@GMAIL.COM	SELF	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	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
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
2157	2024-04-17 11:16	Anonymous (not verified)	94.188.205.168	LAKESIDE DETAILING LLC	Limited Liability Company	249 EMERALD MEADOWS DR, 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.	2024-04-17	DYLAN MCHUGH	19DMCHUGH@GMAIL.COM	ARNOLDS PARK	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	DYLAN MCHUGH	19DMCHUGH@GMAIL.COM	SELF	ARNOLDS PARK	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
231	2020-08-13 18:22	Anonymous (not verified)	173.27.28.18	Kelley Contracting	Proprietorship	115 Pinecrest Circle Elk Run Heights, Ia 50707	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-13	Chad Kelley	chadkelley22@gmail.com	Elk Run Heights	Black Hawk	Iowa	Jack Kelley	Jennifer Kelley	Signed	(1) The employer does not elect the employers’ liability coverage.	Kelley Contracting	chadkelley22@gmail.com	Self	Elk Run Heights	Black Hawk	Iowa	Jack Kelley	Jennifer Kelley	Signed
916	2022-02-16 09:23	Anonymous (not verified)	173.18.22.217	Cesar Ponce	Proprietorship	150 Aspen Dr. Norwalk 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.	2022-02-16	Cesar Ponce	cesarponce00@icloud.com	Nowalk	Warren	Iowa	Lesa Reeves	Jennifer Lambert	Signed	(1) The employer does not elect the employers’ liability coverage.	Cesar Ponce	cesarponce00@icloud.com	Owner	Norwalk	Warren	Iowa	Lesa Reeves	Jennifer Lambert	Signed
1181	2022-07-06 10:10	Anonymous (not verified)	173.18.22.217	MB Masonry LLC	Limited Liability Company	PO Box 7534	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-06	Mirela Atajic	mbmasonryllc@yahoo.com	Urbandale	Polk	Iowa	Lesa Reeves	Jennifer Lambert	Signed	(1) The employer does not elect the employers’ liability coverage.	Mirela Atajic	mbmasonryllc@yahoo.com	Owner	Urbandale	Polk	Iowa	Lesa Reeves	Jennifer Lambert	Signed
1865	2023-10-09 10:28	Anonymous (not verified)	94.188.205.166	Lori Martinez	Proprietorship	6650 SE 5 TH STREET 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.	2023-10-09	Lori Martinez	azulbenavidez04@gmail.com	Des Moines	Polk	Iowa	R. Mitch Coluzzi	Jennifer Lambert	Signed	(1) The employer does not elect the employers’ liability coverage.	Lori Martinez	azulbenavidez04@gmail.com	Self	Des Moines	Polk	Iowa	R. Mitch Coluzzi	Jennifer Lambert	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
2096	2024-03-14 14:53	Anonymous (not verified)	94.188.205.168	Scott Allen	Proprietorship	2603 Bryant Blvd SW	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-14	Scott Michael Allen	allen.scottm@gmail.com	Cedar Rapids	Linn	Iowa	Daniel Bryant Bliek	Jennifer Lee Allen	Signed	(1) The employer does not elect the employers’ liability coverage.	Scott Michael Allen	allen.scottm@gmail.com	Self	Cedar Rapids	Linn	Iowa	Daniel Bryant Bliek	Jennifer Lee Allen	Signed
811	2021-12-22 17:31	Anonymous (not verified)	166.181.85.89	Demmer Construction	Proprietorship	203 Michigan Ave 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.	2021-12-22	Charles Demmer	charliedemmer@gmail.com	Farley	Dubuque	Ia	Michele Demmer	Jennifer White	Signed	(1) The employer does not elect the employers’ liability coverage.	Charles Demmer	charliedemmer@gmail.com	Self	Farley	Dubuque	Ia	Michele Kay Demmer	Jennifer Marie White	Signed
812	2021-12-22 17:31	Anonymous (not verified)	166.181.85.89	Demmer Construction	Proprietorship	203 Michigan Ave 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.	2021-12-22	Charles Demmer	charliedemmer@gmail.com	Farley	Dubuque	Ia	Michele Demmer	Jennifer White	Signed	(1) The employer does not elect the employers’ liability coverage.	Charles Demmer	charliedemmer@gmail.com	Self	Farley	Dubuque	Ia	Michele Kay Demmer	Jennifer Marie White	Signed
631	2021-09-02 22:46	Anonymous (not verified)	173.23.144.4	Lopez Framing LLC	Limited Liability Company	566 walker 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.	2021-09-02	Diana A Garcia Lopez	lopezframing0702@gmail.com	Des moines	Polk	Iowa	Marlon Lopez	Jennifer Reyes	Signed	(1) The employer does not elect the employers’ liability coverage.	Diana A Garcia Lopez	lopezframing0702@gmail.com	Owner	Des moines	Polk	Iowa	Marlon Lopez	Jennifer 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
913	2022-02-14 18:50	Anonymous (not verified)	72.25.23.147	Teimer Trucking	Limited Liability Company	3277 102nd St. Durant, IA 52747	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-14	Daniel Dennis Treimer	dtreimer65@gmail.com	Tipton	Cedar	Iowa	Barry Boll	Jennifer Treimer	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Dennis Treimer	dtreimer65@gmail.com	Owner	Tipton	Cedar	Iowa	Barry Boll	Jennifer Treimer	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
342	2020-12-28 10:19	Anonymous (not verified)	173.31.147.225	SAUL GUEVARA MEZA	Proprietorship	26 WESTVIEW DRIVE APARTMENT 5 MILFORD IA 51351	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-12-22	SAUL GUEVARA MEZA	ESMEJ2513@GMAIL.COM	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	SAUL GUEVARA MEZA	ESMEJ2513@GMAIL.COM	SELF	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNG WIRTH	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
168	2020-05-28 11:29	Anonymous (not verified)	173.31.147.225	RECYCLED SPIRITS LLC	Limited Liability Company	43 ANN STREET MILFORD IA 51351	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-28	LACEY LAAKE	BLAMB@SPENCERSCHOOLS.ORG	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	LACEY LAAKE	BLAMB@SPENCERSCHOOLS.ORG	SELF	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed
169	2020-05-28 11:31	Anonymous (not verified)	173.31.147.225	RECYCLED SPIRITS LLC	Limited Liability Company	43 ANN ST MILFORD IA 51351	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-28	BETH LAMB	BLAMB@SPENCERSCHOOLS.ORG	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	BETH LAMB	BLAMB@SPENCERSCHOOLS.ORG	SELF	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed
344	2020-12-28 11:31	Anonymous (not verified)	173.31.147.225	JEFFREY GOETZINGER	Proprietorship	2112 ITHACA AVE 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.	2020-12-22	JEFFREY GOETZINGER	WALKERINSURANCE@MCHSI.COM	SPIRIT LAKE	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	JEFFREY GOETZINGER	WALKERINSURANCE@MCHSI.COM	SELF	SPIRIT LAKE	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed
409	2021-02-18 16:35	Anonymous (not verified)	173.31.147.225	MATTHEW MYHRE DBA GUNS GALORE	Proprietorship	2329 220TH AVE 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.	2021-02-18	MATTHEW MYHRE	MYHRE3063@GMAIL.COM	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	MATTHEW MYHRE DBA GUNS GALORE	MYHRE3063@GMAIL.COM	SELF	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed
600	2021-08-12 11:04	Anonymous (not verified)	173.19.179.111	ELIJAH HIX	Proprietorship	PO BOX 465 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.	2021-08-11	ELIJAH HIX	HIXSKIDOO800@GMAIL.COM	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	ELIJAH HIX	HIXSKIDOO800@GMAIL.COM	SELF	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed
636	2021-09-10 14:56	Anonymous (not verified)	173.19.179.111	SHANNON SUNDINE	Proprietorship	513 16TH 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.	2021-09-10	SHANNON SUNDINE	SPSUNDINE@GMAIL.COM	SPIRIT LAKE	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNG WIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	SHANNON SUNDINE	SPSUNDINE@GMAIL.COM	SELF	SPIRIT LAKE	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed
749	2021-11-15 16:05	Anonymous (not verified)	173.31.148.43	CHAMONE SWITZER	Proprietorship	PO BOX 72 FOSTORIA IA 51340	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-15	CHAMONE SWITZER	CHAMONE.SWITZER@GMAIL.COM	FOSTORIA	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNG WIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	CHAMONE SWITZER	CHAMONE.SWITZER@GMAIL.COM	SELF	FOSTORIA	IA	United States	TAMI KILEIN	JENNIFER YOUNGWIRTH	Signed
790	2021-12-14 10:59	Anonymous (not verified)	173.31.148.43	SILVER LAKE ACCOUNTING LLC	Limited Liability Company	178 W BAY 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.	2021-12-13	DARYA GAY	DGAY@SILVERLAKEACCOUNTING.CPA	LAKE PARK	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	DARYA GAY	DGAY@SILVERLAKEACCOUNTING.CPA	SELF	LAKE PARK	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed
792	2021-12-14 13:18	Anonymous (not verified)	173.31.148.43	BLUE WAVE SETTLEMENT LLC	Limited Liability Company	1205 H AVENUE 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.	2021-12-14	SHANNON NORTON	NOERTONSHANNON@YAHOO.COM	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	BLUE WAVE SETTLEMENT LLC	NORTONSHANNON@YAHOO.COM	SELF	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JENNIFER 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
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
1717	2023-06-29 11:42	Anonymous (not verified)	94.188.205.169	POWDER COATING CENTER	Limited Liability Company	61 3RD ST NE 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.	2023-06-28	MATT EMBREY	MSEMBREY21@GMAIL.COM	HARTLEY	OBRIEN	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	MATT EMBREY	MSEMBREY21@GMAIL.COM	OWNER	HARTLEY	OBRIEN	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed
1856	2023-09-29 13:18	Anonymous (not verified)	94.188.205.166	MUESSIGMANN ENTERTAINMENT LLC	Limited Liability Company	906 2ND AVE SE 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.	2023-09-27	JON MUESSIGMANN	MUESSIGMANNENT@GMAIL.COM	SPENCER	CLAY	Iowa	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	JON MUESSIGMANN	MUESSIGMANNENT@GMAIL.COM	SELF	SPENCER	CLAY	Iowa	TAMI KLEIN	JENNIFER YOUNGWIRTH	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
322	2020-11-17 14:06	Anonymous (not verified)	208.126.118.26	Wada Farms	Limited Liability Company	2428 270th st Grand Mound, IA 52751	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-11-17	Wade Smith	wade.smith1110@gmail.com	Grand Mound	Clinton	Iowa	Megan Fuglsang	Jenny Gordon	Signed	(1) The employer does not elect the employers’ liability coverage.	Wada Farms	wade.smith1110@gmail.com	self	Grand Mound	clinton	Iowa	Megan Fuglsang	Jenny Gordon	Signed
649	2021-09-21 13:15	Anonymous (not verified)	208.126.118.26	Wade Smith DBA WADA Farms	Proprietorship	2428 270th st, Grand Mound, IA 52751	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-09-21	Wade Smith	wade.smith1110@gmail.com	Grand Mound	Clinton	Iowa	Megan Fuglsang	Jenny Gordon	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Wade Smith	wade.smith1110@gmail.com	self	Grand Mound	Clinton	Iowa	Megan Fuglsang	Jenny Gordon	Signed
685	2021-10-20 14:14	Anonymous (not verified)	65.144.174.26	william c sawhill	Proprietorship	1625 Delaware Ave, Des Moines, 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-20	William C Sawhill	workorders@shoproyalflooring.com	Des Moines	Polk	Iowa	Nicholas W Sawhill	Jenny M Steben	Signed	(1) The employer does not elect the employers’ liability coverage.	William C Sawhill	workorders@shoproyalflooring.com	Self	Des Moines	Polk	Iowa	Nicholas W Sawhill	Jenny M Steben	Signed
184	2020-06-12 10:38	Anonymous (not verified)	174.243.112.246	brian kass	Proprietorship	15064 kass 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.	2020-06-11	brian kass	kass5kass@hotmail.com	dubuque	Iowa	Iowa	kelly kass	jenny McIntyre	Signed	(1) The employer does not elect the employers’ liability coverage.	brian kass	kass5kass@hotmail.com	self	dubuque	Iowa	iowa	Kelly Kass	Jenny McIntyre	Signed
1138	2022-06-01 15:01	Anonymous (not verified)	173.18.233.175	Roy Rohwedder	Proprietorship	296 24th Ave SW Cedar Rapids, IA 52404	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-01	Roy h Rohwedder	rohwedder.roy@yahoo.com	Cedar Rapids	linn	iowa	Cash Rohwedder	Brian Ashlock	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Ashlock	brian@tricounty-iowa.com	Genaral Manager	Cedar Rapids	Linn	IOWA	Branden Peters	Jenny Vaske	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
2147	2024-04-12 11:52	Anonymous (not verified)	94.188.205.166	Tri County Enterprise	Partnership	5527 Crane Lane 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.	2024-04-12	Ken McGraw	kenmcgraw1974@gmail.com	Center Point	IA	United States	bob nissen	Jenny Vaske	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Ashlock	brian@tricounty-iowa.com	General Manager	Shellsburg	IA	United States	bob Nissen	Jenny Vaske	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
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
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
147	2020-05-02 09:07	Anonymous (not verified)	75.162.65.142	Tim Soy	Proprietorship	3506 Amherst Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-01	Timothy Soy	kingsoyboy@hotmail.com	Des Moines	Polk	Iowa	Aaron Page	Jeremy Lukehart	Signed	(1) The employer does not elect the employers’ liability coverage.	Timothy Soy	kingsoyboy@hotmail.com	Self	Des Moines	Polk	Iowa	Aaron page	Jeremy Lukehart	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
1318	2022-09-22 11:18	Anonymous (not verified)	50.82.91.213	J. Thompson Builders, LLC	Limited Liability Company	5291 Stoney Creek 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.	2022-09-22	Christopher Jacob Von Arx	cjvonarx@hotmail.com	Van Wert IA	Decatur IA	Iowa	Christina Viehauser	Jeremy Thompson	Signed	(1) The employer does not elect the employers’ liability coverage.	Christina Viehauser	christina@jthompsonbuilders.com	Office Help	Johnston Ia	Polk	IA	Chris Von Arx	Jeremy Thompson	Signed
1319	2022-09-22 11:31	Anonymous (not verified)	50.82.91.213	J. Thompson Builders, LLC	Limited Liability Company	5291 Stoney Creek 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.	2022-10-22	Mark Grant	mjgrant1957@gmail.com	Adel	Dallas	IA	Christina Viehauser	Jeremy Thompson	Signed	(1) The employer does not elect the employers’ liability coverage.	Christina Viehauser	christina@jthompsonbuilders.com	Office Help	Johnston Ia	Polk	IA	Chris Von Arx	Jeremy Thompson	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
2091	2024-03-12 15:23	Anonymous (not verified)	94.188.205.166	Shelley onnen	Proprietorship	1319 West 2nd 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.	2024-03-12	Shelley L Onnen	Shelleyonnen47@gmail.com	PERRY	IA	United States	Matthew Dean Rote	Jerica Renae Wiborg	Signed	(1) The employer does not elect the employers’ liability coverage.	Shelley L Onnen	Shelleyonnen47@gmail.com	Self	PERRY	IA	United States	Matthew Dean Rote	Jerica Renae Wiborg	Signed
1311	2022-09-15 16:49	Anonymous (not verified)	174.235.213.195	JJ Jones contracting	Limited Liability Company	2413 Valley High 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.	2022-09-15	Justin Jones	jjjonescontractingllc@gmail.com	Cedar Falls	Black Hawk	IA	Dahoni Jones	Jerold Cemrick Jones	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Jones	jjjonescontractingll@gmail.com	Self	Cedar Falls	Black Hawk	IA	Dahoni Jones	Jerold Cemrick Jones	Signed
1353	2022-10-31 21:35	Anonymous (not verified)	50.82.84.225	Jerry Bassett	Proprietorship	108 NE 22 Cr	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-31	Jerry Bassett	JerryDebBassett@aol.com	GRIMES	IA	United States	Deb Bassett	Jerry Bassett	Signed	(1) The employer does not elect the employers’ liability coverage.	Jerry Bassett	JerryDebBassett@aol.com	Self	Grimes	Polk	Iowa	Deb Bassett	Jerry Bassett	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
1952	2023-12-12 13:26	Anonymous (not verified)	94.188.205.167	Austin Albin	Proprietorship	2263 Railroad Street, Jacksonville, IL 62650	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-23	Austin R Albin	albinaustin12@gmail.com	Jacksonville	Morgan	IL	Wayne Albin	Jerry Roth	Signed	(1) The employer does not elect the employers’ liability coverage.	Austin R Albin	albinaustin12@gmail.com	Self	Jacksonville	Morgan	IL	Wayne Albin	Jerry Roth	Signed
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
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
635	2021-09-10 13:41	Anonymous (not verified)	166.181.84.226	JZH Roofing Specialists LLC	Limited Liability Company	2127 Swan Dr, 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.	2021-09-10	Jayme Alexander Christian Heiselman	wrkhrd2plyhrd04@gmail.com	Norwalk	Warren	Iowa	Melanie Handy	Jesse Hagge	Signed	(1) The employer does not elect the employers’ liability coverage.	Jayme Alexander Christian Heiselman	wrkhrd2plyhrd04@gmail.com	Single member	Norwalk	Warren	Iowa	Melanie Handy	Jesse Hagge	Signed
1073	2022-04-27 08:44	Anonymous (not verified)	173.187.173.190	black squirrel siding llc	Limited Liability Company	1512 North first ave apartment C203S Coralville, Iowa 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.	2022-04-27	Lawerance James Brockert	ozzman52382007@yahoo.com	Atalissa	Muscatine	Iowa	Rob Bartosh	Jesse Minor-Nidey	Signed	(1) The employer does not elect the employers’ liability coverage.	Lawerance James Brockert	ozzman523582007@yahoo.com	self	Atalissa	Muscatine	Iowa	Rob Bartosh	Jesse Minor-Nidey	Signed
1028	2022-04-02 11:01	Anonymous (not verified)	174.198.64.100	Great-Dain Htg/Ac & Plumbing	Proprietorship	1616 Maple Rd. Harlan, Iowa 51537	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-02	Richard Nee	great-dain@hotmail.com	Harlan	Shelby	Iowa	Doug Clark	Jesse Nee	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard Nee	great-dain@hotmail.com	Self	Harlan	Shelby	Iowa	Doug Clark	Jesse Nee	Signed
1425	2023-01-18 15:20	Anonymous (not verified)	174.228.35.74	Great-Dain Htg/Ac & Plumbing	Proprietorship	1616 Maple Rd Harlan, Iowa 51537	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-18	Richard Presly Nee	great-dain@hotmail.com	Harlan	Shelby	IA	Theresa Clark	Jesse Nee	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard Presley Nee	great-dain@hotmail.com	Self	Harlan	Shelby	IA	Theresa Clark	Jesse Nee	Signed
996	2022-03-22 23:37	Anonymous (not verified)	173.27.235.109	patriot t services	Proprietorship	205 park st 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.	2022-03-22	TRAVIS KEENEY	knytrav@aol.com	carlisle	warren	iowa	james Ren	Jesse Parker	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Keeney	knytrav@aol.com	myself	carlisle	warren	iowa	james ren	jesse parker	Signed
1393	2022-12-13 12:45	Anonymous (not verified)	50.82.133.22	Ponderosa Outdoor	Limited Liability Partnership	104 Vista Dr Montezuma, Ia 50171	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-13	Daniel Deaver	ponderosaoutdoor@gmail.com	Altoona	Polk	Iowa	Faith Deaver	Jessi Perkins	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Deaver	ponderosaoutdoor@gmail.com	self	Altoona	Polk	Iowa	Faith Deaver	Jessi Perkins	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
9	2019-12-16 11:33	Anonymous (not verified)	50.81.115.85	Travis Garrett and Caleb Elliott	Partnership	P.O. Box 55, 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.	2019-12-16	Travis Garrett	onethird4599@gmail.com	Boone	Boone	IA	Katie Frame	Jessica Carroll	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Garrett & Caleb Elliott	onethird4599@gmail.com	Owner	Boone	Boone	IA	Katie Frame	Jessica Carroll	Signed
10	2019-12-16 11:35	Anonymous (not verified)	50.81.115.85	Travis Garrett and Caleb Elliott	Partnership	P.O. Box 55, 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.	2019-12-16	Caleb Elliott	onethird4599@gmail.com	Boone	Boone	IA	Katie Frame	Jessica Carroll	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Garrett & Caleb Elliott	onethird4599@gmail.com	Owner	Boone	Boone	IA	Katie Frame	Jessica Carroll	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
1882	2023-10-27 10:40	Anonymous (not verified)	94.188.205.166	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.	2025-02-02	Ron Heggebo	heggebojessica@yahoo.com	Vinton	Benton	IA	Jessica Heggebo	Jessica Heggebo	Signed	(1) The employer does not elect the employers’ liability coverage.	Ronnie Heggebo	heggebojessica@yahoo.com	self	Vinton	Benton	IA	Jessica Heggebo	Jessica Heggebo	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
1416	2023-01-09 13:05	Anonymous (not verified)	67.55.184.55	Austin Lanz	Proprietorship	3015 M Ave.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-09	Austin Robert Lanz	austinlanz52@gmail.com	Moring Sun	Iowa	IA	Robert Lowell Lanz	Jessica Leann Ewart	Signed	(1) The employer does not elect the employers’ liability coverage.	Austin Robert Lanz	austinlanz52@gmail.com	Self	Moring Sun	Iowa	IA	Robert Lowell Lanz	Jessica Leann Lanz	Signed
1307	2022-09-14 13:40	Anonymous (not verified)	216.51.227.123	elite business ckeaning	Proprietorship	1350 kennel ct unit c2 north liberty IA 52317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-14	rogelio morales ortega	info@elitebusinesscleaning.com	iowa city	johnson	iowa	cesar morales ortega	alma rosa perez	Signed	(1) The employer does not elect the employers’ liability coverage.	elite busibess cleaning	info@elitebusinesscleaning.com	president	north liberty	johnson	iowa	karina aguilar	jessica lee	Signed
487	2021-04-20 11:10	Anonymous (not verified)	207.191.193.167	Chento Construction	Proprietorship	702 Lincoln St. Ainsworth, IA 52201	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-05	Alberto Garcia	chentoconstruction@hotmail.com	Ainsworth	Washington	Iowa	Anthony Johnson	Jessica Lopez	Signed	(1) The employer does not elect the employers’ liability coverage.	Alberto Garcia	chentoconstruction@hotmail.com	Owner	Ainsworth	Washington	Iowa	Anthony Johnson	Jessica Lopez	Signed
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
1870	2023-10-17 16:13	Anonymous (not verified)	94.188.205.176	Diamond ridge	Proprietorship	1842 Glenwood cir 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.	2023-10-17	Marianna Landeros	cheri6876@yahoo.com	Des moines	Polk	Iowa	Marianna Landeros	Cheri Martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Marianna Landeros	landerosmary@gmail.com	Self	Des Moines	Polk	Iowa	Cheri Martinez	Jessica Newton	Signed
71	2020-02-21 05:24	Anonymous (not verified)	70.100.107.197	CRS Inc.	Proprietorship	1442 3rd 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.	2020-01-20	Monica Christensen	monicalchristensen@gmail.com	Belmond	Wright	Iowa	Jessica Tempus	Dawn Butler	Signed	(1) The employer does not elect the employers’ liability coverage.	Monica Christensen	monicalchristensen@gmail.com	Consultant	Belmond	Iowa	United States	Dawn Butler	Jessica Tempus	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
681	2021-10-19 15:44	Anonymous (not verified)	65.144.174.26	Humberto Albino	Proprietorship	3914 Aurora 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.	2021-10-19	Humberto Albino	albinohumberto73@gmail.com	Des Moines	Polk	Iowa	Miguel Albino	Jesus Albino	Signed	(1) The employer does not elect the employers’ liability coverage.	Humberto Albino	albinohumberto73@gmail.com	Owner	Des Moines	Polk	Iowa	Miguel Albino	Jesus Albino	Signed
245	2020-08-25 15:20	Anonymous (not verified)	107.77.207.111	J&R cleaning co LLC	Limited Liability Company	14300 Holcomb ave #210 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	José A salas romero	chinito80sr@hotmail.com	Desmoines	Polk	Iowa	Ana López	Jesus gonzales	Signed	(1) The employer does not elect the employers’ liability coverage.	José romero	chinito80sr@hotmail.com	Owner	Desmoines	Polk	Iowa	Ana lopez	Jesus Gonzales	Signed