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:
747	2021-11-12 15:08	Anonymous (not verified)	75.162.157.80	Unique Hardwood Floors, LLC	Limited Liability Company	1202 Army Post Rd. des Moines, Iowa 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-12	Jose A Dominguez Lopez	uniquefloorsdmi@gmail.com	Des Moines	USA	Iowa	Elizabeth Dominguez	Liliana Sanchez Gutierrez	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose A Dominguez Lopez	uniquefloorsdmi@gmail.com	Owner	Des Moines	USA	Iowa	Elizabeth Dominguez	Liliana Sanchez Gutierrez	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
44	2020-01-28 12:55	Anonymous (not verified)	173.24.181.211	AMANDA FIEDLER	Proprietorship	10 5TH AVE NW 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.	2020-01-28	AMANDA FIEDLER	JOEL@WALKERINSURANCEIA.COM	FOSTORIA	CLAY	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	AMANDA FIEDLER	JOEL@WALKERINSURANCEIA.COM	OWNER	FOSTORIA	CLAY	IA	JOSPH THOMAS LORING	TAMI SUE KLEIN	Signed
1343	2022-10-25 11:25	Anonymous (not verified)	97.125.43.203	Midwest Pro Construction LLC	Limited Liability Company	1000 SE 11th St Apt 3202	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-17	Laura Garcia	deb@piciowa.com	Grimes	polk	Iowa	Debra Stratton	Kenneth Stratton	Signed	(1) The employer does not elect the employers’ liability coverage.	Laura Garcia	deb@piciowa.com	self	Grimes	Polk	Iowa	Debra Stratton	Kenneth Stratton	Signed
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
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
18	2019-12-31 13:36	Anonymous (not verified)	162.253.44.28	Wade Roth DBA Roth TV and Appliance	Proprietorship	1004 12th St, Belle Plaine, IA 52208	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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.	2019-12-09	Wade Roth	WADEROTH@NETINS.NET	Belle PLaine	Benton	Iowa	Robert Sydnes	Robert Sydnes	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Wade Roth	WADEROTH@NETINS.NET	Self	Belle Plaine	Benton	Iowa	Robert Sydnes	Kurt Feller	Signed
770	2021-11-22 18:17	Anonymous (not verified)	192.82.97.13	Paul Wire	Proprietorship	1005 25th Street SW, 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.	2021-11-22	Paul Wire	gizzmochee@gmail.com	Spencer	Clay	IA	Lori Wire	Abigail Miles	Signed	(1) The employer does not elect the employers’ liability coverage.	Paul Wire	gizzmochee@gmail.com	Self	Spencer	Clay	IA	Lori Wire	Abigail Miles	Signed
896	2022-02-04 11:58	Anonymous (not verified)	198.167.180.146	Northtowne Market Lot 7, LLC	Limited Liability Company	1005 Blairs Ferry Road NE, Cedar Rapids, IA 52404	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-04	Benjamin Wickum	bwickum@collinscu.org	CEDAR RAPIDS	Linn	Iowa	Jody Comried	Pat Milke	Signed	(1) The employer does not elect the employers’ liability coverage.	Benjamin Wickum	bwickum@collinscu.org	Manager	Cedar Rapids	Linn	Iowa	Jody Comried	Pat Milke	Signed
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
1418	2023-01-11 10:44	Anonymous (not verified)	173.23.144.232	precision edge llc	Limited Liability Company	101 belmont st milo iowa 50116	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-10	erik reha	precisionedgecompanies@gmail.com	milo	warren	iowa	bruce wilson	jordan rhode	Signed	(1) The employer does not elect the employers’ liability coverage.	n/a	precisionedgecompanies@gmail.com	n/a	n/a	n/a	n/a	bruce wilson	jordan rhode	Signed
402	2021-02-15 16:33	Anonymous (not verified)	66.188.136.150	K.C. Ansel	Proprietorship	101 Cherokee Dr. Dubuque, IA 52003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-15	K.C. Ansel	kschumacher@tricorinsurance.com	Dubuque	Dubuque	IA	Russell Masartis	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	K.C. Ansel	kschumacher@tricorinsurance.com	Same	Dubuque	Dubuque	IA	Russell Masartis	Shuree Behr	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
983	2022-03-18 11:02	Anonymous (not verified)	66.180.9.84	Gary Runyon	Proprietorship	101 Harris St Ste 1 Hastings, IA 51540	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-18	Gary Runyon	garyrunyon26@gmail.com	Henderson	Mills	Iowa	Gary Runyon	Cathy Mardesen	Signed	(1) The employer does not elect the employers’ liability coverage.	Gary Runyon	garyrunyon26@gmail.com	owner	Henderson	Mills	Iowa	Gary Runyon	Cathy Mardesen	Signed
837	2022-01-13 08:38	Anonymous (not verified)	169.197.65.8	Reyes Concrete Services llc	Limited Liability Company	101 Perry St South Jesup, 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.	2022-01-13	Ronald Reyes	ronlreyes1975@gmail.com	Jesup	Buchanan	Iowa	Jacolin Reyes	Ronald Reyes	Signed	(1) The employer does not elect the employers’ liability coverage.	Ronald Reyes	ronlreyes1975@gmail.com	Same	Jesup	Buchanan	Iowa	Jacolin Reyes	Ronald Reyes	Signed
113	2020-04-07 12:30	Anonymous (not verified)	173.27.33.108	Aarron Alley	Proprietorship	101 S Teale 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.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2018-05-15	Aarron Alley	aarronalley10@yahoo.com	Davis City	Decatur	Iowa	Joe Fitzgerald	Steve Young	Signed	(1) The employer does not elect the employers’ liability coverage.	Aarron Alley	aarronalley10@yahoo.com	Owner	Davis City	Decatur	Iowa	Joe Fitzgerald	Steve Young	Signed
308	2020-11-08 09:17	Anonymous (not verified)	173.27.33.108	Aarron Alley	Proprietorship	101 S Teale St. Davis City, 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.	2019-11-01	Aarron Alley	aarronalley10@yahoo.com	Davis City	Decatur	Iowa	Joe Fitzgerald	Steve Young	Signed	(1) The employer does not elect the employers’ liability coverage.	Aarron Alley	aarronalley10@yahoo.com	Owner	Davis City	Decatur	Iowa	Joe Fitzgerald	Steve Young	Signed
997	2022-03-23 06:15	Anonymous (not verified)	167.142.233.235	Betsy Harms Agency LLC	Limited Liability Company	101 Sherman Ave, Ackley, IA 50601	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-23	Betsy Harms	bharms@phillipsstafford.com	Ackley	Franklin	IA	Levi Harms	Patricia Harms	Signed	(1) The employer does not elect the employers’ liability coverage.	Betsy Harms	bharms@phillipsstafford.com	Self	Ackley	Franklin	IA	Levi Harms	Patricia Harms	Signed
2059	2024-02-27 11:44	Anonymous (not verified)	94.188.205.169	Dowdey Construction LLC	Limited Liability Company	1010 19th Ave - Rock Valley, IA 51247	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-27	Nicholas Allen Dowdey	nddowdey@hotmail.com	Rock Valley	Sioux	Iowa	Deidre Dawn Dowdey	Alexander C Koedam	Signed	(1) The employer does not elect the employers’ liability coverage.	Nicholas Allen Dowdey	nddowdey@hotmail.com	Self	Rock Valley	Sioux	Iowa	Deidre Dawn Dowdey	Alexander C Koedam	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
561	2021-07-08 09:11	Anonymous (not verified)	66.188.136.150	Aaron Maldonado dba ATM Trucking	Proprietorship	1011 Reynolds Drive, Charleston, IL 61920	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-07	Aaron Maldonado dba ATM Trucking	kschumacher@tricorinsurance.com	Charleston	Coles	IL	Mitch Kemp	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Aaron Maldonado dba ATM Trucking	kschumacher@tricorinsurance.com	Same	Charleston	Coles	IL	Mitch Kemp	Shuree Behr	Signed
1658	2023-05-23 09:56	Anonymous (not verified)	94.188.205.168	M&D Webster Construction Inc	Proprietorship	1012 Creek Street Webster City IA 50595	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-28	David Gomez	office.seamlesspros@icloud.com	Webster City	Hamilton	Iowa	Jessica Knutson	Keith Clabaugh	Signed	(1) The employer does not elect the employers’ liability coverage.	David Gomez	office.seamlesspros@icloud.com	Self	Webster City	Hamilton	Iowa	Jessica Knutson	Keith Clabaugh	Signed
2151	2024-04-15 14:42	Anonymous (not verified)	94.188.207.227	Jose Acuna	Proprietorship	1015 East Main Street, Belmond, IA 50421, US	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-15	Jose Acuna	Joseacuna@gmail.com	Belmond, IA	Wright	Iowa	Jordan Loyd	Jordan Nisiewicz	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Johnson	Missouri	Jordan Loyd	Cody Dunbar	Signed
1835	2023-09-09 15:11	Anonymous (not verified)	94.188.207.224	Heartland Ultrasonography Group	Limited Liability Company	1015 Woodland Dr Carlisle, IA 50047	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-09	Micah Ezra Wiele	mewiele99@gmail.com	Ankeny	Polk	Iowa	Nathan Miguel Diaz	Brandon Allen Pemoulie	Signed	(1) The employer does not elect the employers’ liability coverage.	Micah Ezra Wiele	heartlandusgroup@outlook.com	Co-owner	Ankeny	Polk	Iowa	Nathan Miguel Diaz	Brandon Allen Pemoulie	Signed
1614	2023-04-27 15:18	Anonymous (not verified)	94.188.205.177	Crawford Construction Services LLC	Limited Liability Company	1018 Creston Ave, Des Moines, Ia 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-27	Casey D Crawford	crawfordcasey8824@gmail.com	Des Moines	Polk	Iowa	Nicole Powell	Steve Crawford	Signed	(1) The employer does not elect the employers’ liability coverage.	Casey D Crawford	crawfordcasey8824@gmail.com	Owner	Des Moines	Polk	Iowa	Nicole Powell	Steve Crawford	Signed
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
350	2021-01-04 09:35	Anonymous (not verified)	173.29.234.11	Plum Communications, LLC	Limited Liability Company	1018 NW Campus Ridge CT, Ankeny, IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-01	Brian Shearer	brian@plumllc.com	Ankeny	Polk	IA	Brian Shearer	Brian Shearer	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Shearer	brian@plumllc.com	Owner	Ankeny	Polk	IA	Brian Shearer	Brian Shearer	Signed
823	2022-01-05 16:35	Anonymous (not verified)	173.29.232.165	Plum Communications, LLC	Limited Liability Company	1018 NW Campus Ridge CT, Ankeny, IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-01	Brian Shearer	brian@plumllc.com	Ankeny	Polk	Iowa	Brian Shearer	Brian Shearer	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Shearer	brian@plumllc.com	Owner	Ankeny	Polk	IA	Brian Shearer	Brian Shearer	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
740	2021-11-11 14:54	Anonymous (not verified)	72.13.16.172	LECHTENBERG TRUCKING LLC	Limited Liability Company	10185 HWY 18	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-11-18	LECHTENBERG TRUCKING LLC	dave@allseasonstrucking.com	POSTVILLE	CLAYTON	IA	Dave Neuwohner	BEN MOYER	Signed	(1) The employer does not elect the employers’ liability coverage.	LECHTENBERG TRUCKING LLC	dave@allseasonstrucking.com	PRESIDENT	POSTVILLE	CLAYTON	IA	Dave Neuwohner	BEN MOYER	Signed
1515	2023-03-13 15:04	Anonymous (not verified)	94.188.207.226	Flint Hillman	Proprietorship	1019 E 17th St, APT 16, Norwalk, IA 50211	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-13	Flint Hillman	flinthillman@gmail.com	Norwalk	Warren	Iowa	Tina Robinson	Paige Robinson	Signed	(1) The employer does not elect the employers’ liability coverage.	Flint Hillman	flinthillman@gmail.com	Self	Norwalk	Warren	Iowa	Tina Robinson	Paige Robinson	Signed
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
991	2022-03-21 15:25	Anonymous (not verified)	64.191.6.226	Wheeler Painting	Proprietorship	102 Maple Circle Waverly Iowa 50677	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-21	Jon Wheeler	jon.wheeler67@gmail.com	Waverly	Bremer	Iowa	Jason Grant	Richard Grant	Signed	(1) The employer does not elect the employers’ liability coverage.	Jon Wheeler	jon.wheeler67@gmail.com	Owner	Waverly	Bremer	Iowa	Jason Grant	Richard Grant	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
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
316	2020-11-13 11:46	Anonymous (not verified)	66.188.136.150	Canebreak & Warlander Trucking, LLC	Limited Liability Company	1020 Avenue F, Fort Madison, IA 52627	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Canebreak & Warlander Trucking LLC	kschumacher@tricorinsurance.com	Fort Madison	Lee	IA	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	Canebreak & Warlander Trucking LLC	kschumacher@tricorinsurance.com	Same	Fort Madison	Lee	IA	Russell Masartis	Nancy Wortley	Signed
1358	2022-11-03 23:03	Anonymous (not verified)	172.86.32.251	LeafFilter North LLC	Limited Liability Company	1020 James Drive Suite A \| Hartland, WI 53209	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-03	Aaron Bensinger	guttershereandnow@outlook.com	Marion	Linn	Iowa	Silvena Cammareri	Aaron Bensinger	Signed	(1) The employer does not elect the employers’ liability coverage.	Aaron Bensinger	guttershereandnow@outlook.com	Self	Marion	Linn	Iowa	Aaron Bensinger	Silvena Cammareri	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
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
596	2021-08-04 10:48	Anonymous (not verified)	184.80.177.137	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.	2021-08-04	Steve Knipper	jheims@english-insurance.com	Dyersville	Dubuque	IA	Derrick Parsons	Joyce Heims	Signed	(1) The employer does not elect the employers’ liability coverage.	Joyce Heims	jheims@english-insurance.com	agent	Dyersville	Dubuque	IA	Derrick Parsons	Joyce Heims	Signed
1182	2022-07-06 13:40	Anonymous (not verified)	50.80.25.116	Beast Construction LLC	Limited Liability Company	1025 O Ave NW	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-11	Gilberto Vasquez (GV Construction LLC)	Normambazquez@gmail.com	Iowa City	IA	United States	Pedro Pinto	Rafael Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Greg Saunders	gsaunders@beastconstructioncr.com	Owner	CEDAR RAPIDS	IA	United States	Laura Saunders	Joanie Lacayo	Signed
1093	2022-05-12 06:32	Anonymous (not verified)	50.80.25.116	Beast Construction LLC	Limited Liability Company	1025 O Ave 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.	2022-02-01	Catarino Martinez Alvarez - H&C Roofing LLC	handc.rconst@outlook.com	North Liberty	Johnson	Iowa	Evelyn Lagos	Edgardo Hernandez	Signed	(1) The employer does not elect the employers’ liability coverage.	Greg Saunders	Gsaunders@beastconstructioncr.com	Owner	Cedar Rapids	Linn	Iowa	Laura Sturm	Joanie Lacayo	Signed
1333	2022-10-13 14:01	Anonymous (not verified)	174.192.85.141	Terry Smith	Proprietorship	1028 14th Avenue Fulton il	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-14	Terry Smith	terry1270smith@gmail.com	Fulton	IL	United States	Angela Smith	Tracey Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Terry Smith	terry1270smith@gmail.com	Wife	Fulton	IL	United States	Angie Smith	Tracey smith	Signed
928	2022-02-17 19:46	Anonymous (not verified)	208.83.187.211	Eric Marsh Trucking LLC	Limited Liability Company	1029 Davis Ave Westbrook MN 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.	2022-02-17	Eric Marsh	emt78@yahoo.com	Westbrook	Cottonwood	MN	Dustin Krick	Sam Hansen	Signed	(1) The employer does not elect the employers’ liability coverage.	Eric Marsh	emt78@yahoo.com	Self	Westbrook	Cottonwood	MN	Dustin Krick	Sam Hansen	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
566	2021-07-08 14:19	Anonymous (not verified)	50.82.130.211	Black Cat Ice Cream, LLC	Limited Liability Company	1031 Office Park Road, Suite #4, 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.	2021-06-10	David Boelman	cmins_re@mchsi.com	Des Moines	Polk	Iowa	Mary Brown	Kaytee Stearns	Signed	(1) The employer does not elect the employers’ liability coverage.	Black Cat Ice Cream, LLC	cmins_re@mchsi.com	Self	Des Moines	Polk	Iowa	Mary Brown	Kaytee Stearns	Signed
567	2021-07-08 14:22	Anonymous (not verified)	50.82.130.211	Black Cat Ice Cream, LLC	Limited Liability Company	1031 Office Park Road, Suite #4, 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.	2021-06-10	Alex Carter	cmins_re@mchsi.com	Des Moines	Polk	Iowa	Mary Brown	Kaytee Stearns	Signed	(1) The employer does not elect the employers’ liability coverage.	Black Cat Ice Cream, LLC	cmins_re@mchsi.com	Self	Des Moines	Polk	Iowa	Mary Brown	Kaytee Stearns	Signed
2007	2024-01-29 13:13	Anonymous (not verified)	94.188.205.174	Saratoga Seamless Gutters LLC	Limited Liability Company	10328 Howard Ave, Lime Springs, IA 52155	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-29	Michael Langlais	saratogaseamlessgutters@gmail.com	Lime Springs	Howard	IA	Amanda Doty	Michaela Langlais	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Langlais	saratogaseamlessgutters@gmail.com	Owner	Lime Springs	Howard	IA	Amanda Doty	Michaela Langlais	Signed
483	2021-04-16 10:47	Anonymous (not verified)	204.155.61.217	Joseph Jones DBA Jones Sealcoating and Asphalt Repair	Limited Liability Company	1033 Hummingbird 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.	2021-04-16	Joseph Jones	iscrapcu@yahoo.com	Waterloo	Iowa	Iowa	Kyle Hildman	Dan Sinnott	Signed	(1) The employer does not elect the employers’ liability coverage.	Jospeh Jones	iscrapcu@yahoo.com	OWNER	Waterloo	Black Hawk	IA	Kyle Hildman	Dan Sinnott	Signed
1639	2023-05-11 07:39	Anonymous (not verified)	94.188.205.175	JYC Drywall LLC	Proprietorship	1034 Grand Ave, Muscatine, IA 52761	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-11	Anastacio Zamarripa	1zama0081@gmail.com	Muscatine	Louisa	Iowa	Arcel Servin	Chris Hay	Signed	(1) The employer does not elect the employers’ liability coverage.	Anastacio Zamarripa	1zama0081@gmail.com	Self	Muscatine	Louisa	Iowa	Arcel Servin	Chris Hay	Signed
1247	2022-08-08 16:43	Anonymous (not verified)	72.13.27.236	Williams Hardwood Flooring LLC	Limited Liability Company	10359 Deer Trail	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-05	Chad Everett Williams	williamshardwood@aol.com	Anamosa	IA	IA	Shane Kies	Dave Reitseger	Signed	(1) The employer does not elect the employers’ liability coverage.	Chad Everett Williams	williamshardwood@aol.com	Owner	Anamosa	IA	IA	Shane Kies	Dave Reitseger	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
454	2021-03-26 09:46	Anonymous (not verified)	50.82.130.211	Jason Thoren	Proprietorship	104 1st Street NW, Tripoli, IA 50676	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-04	Jason Thoren	cmins_re@mchsi.com	Tripoli	Bremer	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Thoren	cmins_re@mchsi.com	Self	Tripoli	Bremer	Iowa	Chad Campbell	Roxanne Kolder	Signed
387	2021-02-08 14:26	Anonymous (not verified)	192.30.185.142	Go 2 Girls	Proprietorship	104 Doral Lane, Dakota Dunes, SD 57049	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-08	Tawnya Oneill	tawny5881@gmail.com	Dakota Dunes	Union	SD	Katie Jenks	Virginia Anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Tawnya Oneill	tawny5881@gmail.com	Owner	Dakota Dunes	Union	SD	Katie Jenks	Virginia Anderson	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
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
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
1012	2022-03-28 14:42	Anonymous (not verified)	97.125.50.9	Charles Grimes	Proprietorship	1041 NW Victoria Ln, Waukee, IA 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-28	Charles Grimes	maurcedes98@gmail.com	Waukee	Dallas	Iowa	Dave Tomlin	Lavon Grimes	Signed	(1) The employer does not elect the employers’ liability coverage.	Charles Grimes	maurcedes98@gmail.com	self	Waukee	Dallas	IA	Dave Tomlin	Lavon Grimes	Signed
738	2021-11-11 14:38	Anonymous (not verified)	72.13.16.172	MARK ALAN SALATHE	Proprietorship	1042 WELLS 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.	2019-11-18	MARK ALAN SALATHE	dave@allseasonstrucking.com	DARLINGTON	LAFAYETTE	WI	Dave Neuwohner	BEN MOYER	Signed	(1) The employer does not elect the employers’ liability coverage.	MARK ALAN SALATHE	dave@allseasonstrucking.com	PRESIDENT	DARLINGTON	LAFAYETTE	WI	DAVE NEUWOHNER	BEN MOYER	Signed
515	2021-05-11 15:18	Anonymous (not verified)	66.188.136.150	Odie Mitchell	Proprietorship	10441 Serenity Dr. DeMotte, IN 46310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-05	Odie Mitchell	kschumacher@tricorinsurance.com	DeMotte	Jasper	IN	Shuree Behr	Jordan Bass	Signed	(1) The employer does not elect the employers’ liability coverage.	Odie Mitchell	kschumacher@tricorinsurance.com	Same	DeMotte	Jasper	IN	Shuree Behr	Jordan Bass	Signed
516	2021-05-12 12:41	Anonymous (not verified)	66.188.136.150	Odie Mitchell	Proprietorship	10441 Serenity Dr. DeMotte, IN 46310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-05	Odie Mitchell	kschumacher@tricorinsurance.com	DeMotte	Jasper	IN	Shuree Behr	Jordan Bass	Signed	(1) The employer does not elect the employers’ liability coverage.	Odie Mitchell	kschumacher@tricorinsurance.com	Same	DeMotte	Jasper	IN	Shuree Behr	Jordan Bass	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
1794	2023-08-10 14:56	Anonymous (not verified)	94.188.205.169	Alex Kiler	Proprietorship	10511 Main Road, La Porte City, IA 50651, 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.	2023-08-10	Alex Kiler	alexkiler12622@gmail.com	La Porte City, IA	Black Hawk County	Iowa	Charles Woods	Steve Geisler	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Charles Wood	Steven Geisler	Signed
2005	2024-01-29 08:50	Anonymous (not verified)	94.188.207.226	Laser Line Striping	Proprietorship	10572 320th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-29	Dean Weikert	d.lineuponline@yahoo.com	Ackley	Iowa	United States	Linda Weikert	Ca	Signed	(1) The employer does not elect the employers’ liability coverage.	Kain Helmke	d.lineuponline@yahoo.com	D.lineuponline@yahoo.com	Ackley	Butler	Iowa	Linda Weikert	Kain Helmke	Signed
6	2019-11-14 13:09	Anonymous (not verified)	69.18.10.115	Sigourney Heating and Air Conditioning LLC	Limited Liability Company	106 E Washington, Sigourney Iowa 52591	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-11-14	Spencer A Wright	officeshac@gmail.com	Sigourney	Keokuk	Iowa	Darren Diethelm	Myles Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Spencer A Wright	officeshac@gmail.com	Owner	Sigourney	Keokuk	Iowa	Darren Diethelm	Myles Miller	Signed
532	2021-05-27 11:28	Anonymous (not verified)	50.82.70.103	WHAT BBQ & BAR, LLC	Limited Liability Company	106 S CODY RD 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.	2021-05-27	SHILL HUNTER	WHATBBQBAR@GMAIL.COM	LECLAIRE	SCOTT	IOWA	WHITNEY LANE	ROBERT CAIN	Signed	(1) The employer does not elect the employers’ liability coverage.	SHILL HUNTER	WHATBBQBAR@GMAIL.COM	OWNER	LECLAIRE	SCOTT	IOWA	WHITNEY LANE	ROBERT CAIN	Signed
1039	2022-04-11 14:33	Anonymous (not verified)	199.120.121.97	Panama Electric	Proprietorship	106 S Railway Panama IA 51562	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-11	Dan Wingert	danwingert@fmctc.com	Panama	Shelby	IA	Laura Wingert	Sylvan Kenkel	Signed	(1) The employer does not elect the employers’ liability coverage.	Dan Wingert	danwingert@fmctc.com	Self	Panama	Shelby	IA	Laura Wingert	Sylvan Kenkel	Signed
1522	2023-03-16 15:24	Anonymous (not verified)	94.188.205.175	Paul fausett	Proprietorship	1060 Ne 43rd 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.	2023-03-16	Paul Edward fausett jr	pablolow126@gmail.com	Des Moines	Polk	IA	Crista Elizabeth baires	Paul Edward fausett sr	Signed	(1) The employer does not elect the employers’ liability coverage.	Paul Edward fausett jr	pablolow126@gmail.com	Self	Des Moines	Polk	IA	Crista Elizabeth baires	Paul Edward fausett sr	Signed
450	2021-03-25 11:59	Anonymous (not verified)	66.188.136.150	Mason Cook	Proprietorship	10604 Bradford Road, Indianapolis, IN 46231	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-23	Mason Cook	kschumacher@tricorinsurance.com	Indianapolis	Marion	IN	Russell Masartis	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Mason Cook	kschumacher@tricorinsurance.com	Same	Indianapolis	Marion	IN	Russell Masartis	Shuree Behr	Signed
890	2022-02-03 15:11	Anonymous (not verified)	173.23.180.117	E.A. Electric LLC	Limited Liability Company	1065 South Hill 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.	2022-02-03	Emin Alibegic	emin.alibegic@yahoo.com	Waterloo	Black Hawk	Iowa	Nickole Pry	Christine Willis	Signed	(1) The employer does not elect the employers’ liability coverage.	Emin Alibegic	emin.alibegic@yahoo.com	Same Person	Waterloo	Black Hawk	Iowa	Nickole Pry	Christine Willis	Signed
1417	2023-01-11 08:55	Anonymous (not verified)	174.235.209.245	Standard Insulation Company, LLC	Limited Liability Company	1066 Prairieview Ave., Van Meter, IA 50261	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Mitchell Simonson	standard.insulation@outlook.com	Van Meter	Madison	IA	Jeremy Smith	Sue Sherman	Signed	(1) The employer does not elect the employers’ liability coverage.	Mitchell Simonson	standard.insulation@outlook.com	Owner	Van Meter	Madison	IA	Jeremy Smith	Sue Sherman	Signed
1847	2023-09-18 18:20	Anonymous (not verified)	94.188.205.168	William O'Brien	Proprietorship	1069 Yukon Ave Sumner Iowa 50674	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-18	William Charles O'Brien	wcobrien63@gmail.com	Sumner	Bremer	Iowa	Patrick B Dillon	Christina Rader	Signed	(1) The employer does not elect the employers’ liability coverage.	William Charles O'Brien	wcobrien63@gmail.com	self	Sumner	Bremer	Iowa	Patrick B Dillon	Christina Rader	Signed
745	2021-11-11 15:24	Anonymous (not verified)	72.13.16.172	SCHLECHT TRUCKING LLC	Limited Liability Company	107 SOUTH 1ST 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.	2019-11-18	SCHLECHT TRUCKING LLC	dave@allseasonstrucking.com	SPRINGBROOK	JACKSON	IA	Dave Neuwohner	BEN MOYER	Signed	(1) The employer does not elect the employers’ liability coverage.	SCHLECHT TRUCKING LLC	dave@allseasonstrucking.com	PRESIDENT	SPRINGBROOK	JACKSON	IA	Dave Neuwohner	BEN MOYER	Signed
666	2021-10-07 08:12	Anonymous (not verified)	208.126.166.149	Toribio Construction LLC	Limited Liability Company	107 W Maxson 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.	2020-10-07	Jose Toribio	osorioabigail0224@gmail.com	West Liberty	Muscatine	IA	Anthony Johnson	Abigail Osorio	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Toribio	osorioabigail0224@gmail.com	Owner	West Liberty	Muscatine	IA	Anthony Johnson	Abigail Osorio	Signed
497	2021-04-27 09:25	Anonymous (not verified)	204.153.176.147	SHANE HUCK	Proprietorship	1070 305TH STREET, NASHUA, IOWA 50658	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-27	SHANE HUCK	WOODHUCK@GMAIL.COM	NASHUA	CHICKASAW	IOWA	KIM LOECKLE	RACHEL SCHNEIDER	Signed	(1) The employer does not elect the employers’ liability coverage.	SHANE HUCK	WOODHUCK@GMAIL.COM	OWNER	NASHUA	CHICKASAW	IOWA	KIM LOECKLE	RACHEL SCHNEIDER	Signed
2132	2024-04-03 19:49	Anonymous (not verified)	94.188.205.166	Soto Stone LLC	Limited Liability Partnership	1071 mansfield Dr waukee iowa 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2024-04-03	Yesser Lenin Juarez Soto	sotostonellc95@gmail.com	waukee	Dallas	Iowa	Ashley Marie Francisco	Vincent Alexander Flores	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Yesser Lenin Juarez Soto	sotostonellc95@gmail.com	self	waukee	Dallas	Iowa	Ashley Marie Francisco	Vincent Alexander Flores	Signed
2133	2024-04-03 19:58	Anonymous (not verified)	94.188.207.228	Soto Stone LLC	Limited Liability Company	1071 mansfield Dr waukee iowa 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2024-04-03	Yesser Lenin Juarez Soto	sotostonellc95@gmail.com	waukee	Dallas	Iowa	Ashley Marie Francisco	Vincent Alexander Flores	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Yesser Lenin Juarez Soto	sotostonellc95@gmail.com	self	waukee	Dallas	Iowa	Ashley Marie Francisco	Vincent Alexander Flores	Signed
537	2021-06-07 15:25	Anonymous (not verified)	66.188.136.150	Casey Young	Proprietorship	10731 State Highway 118 Turrell, AR 72384	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Casey Young	kschumacher@tricorinsurance.com	Turrell	Crittenden	AR	Mitch Kemp	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Casey Young	kschumacher@tricorinsurance.com	Same	Turrell	Crittenden	AR	Mitch Kemp	Shuree Behr	Signed
527	2021-05-20 07:54	Anonymous (not verified)	66.43.242.142	mcconnells custom construction	Proprietorship	1074 240th 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.	2020-12-01	John McConnell	jnkatmcc@netins.net	jefferson	greene	ia	Jordan Hostetler	Mark Aspengren	Signed	(1) The employer does not elect the employers’ liability coverage.	McConnell's Custom Construction	jnkatmcc@netins.net	owner	jefferson	greene	ia	Jordan Hostetler	Mark Aspengren	Signed
604	2021-08-14 11:18	Anonymous (not verified)	69.54.119.134	Robert Curry	Limited Liability Company	10759 S 96th Ave W Prairie City IA 50228	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-14	Bob Curry	Gardengal4205@gmail.com	Prairie City	IA	United States	Megan Irwin	Rob Irwin	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Curry	Gardengal4205@gmail.com	Self	Prairie City	IA	United States	Megan Irwin	Rob Irwin	Signed
129	2020-04-24 15:28	Anonymous (not verified)	173.28.28.57	Michael Jansen	Proprietorship	108 6th Street, Parkersburg, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-10	Michael G Jansen	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael G Jansen	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
1204	2022-07-14 11:59	Anonymous (not verified)	107.1.252.41	International Drywall LLC.	Limited Liability Company	108 N 4th 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.	2022-07-14	Victoria G Cervantes	vic8.cervantes@gmail.com	Marshalltown	IA	United States	Rodrigo Rodriguez	Juan Cervantes	Signed	(1) The employer does not elect the employers’ liability coverage.	Victoria G Cervantes	Vic8.cervantes@gmail.com	Self	Marshalltown	IA	United States	Rodrigo Rodriguez	Juan Cervantes	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
1687	2023-06-12 16:23	Anonymous (not verified)	94.188.207.229	Jose Manuel Sanchez Loreto	Proprietorship	108 North Hawthorn Drive Altoona, Iowa 50009	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-12	Jose Manual Sanzhez Loreto	jjanna1226@gmail.com	Altoona	Polk	Iowa	Debra Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Manuel Sanchez Loreto	jjana1226@gmail.com	self	Altoona	Polk	Iowa	Debra Stratton	Kelly Denger	Signed
166	2020-05-27 11:48	Anonymous (not verified)	66.188.136.150	Kevin Kerstetter	Proprietorship	1080 E 12th St. Dubuque, IA 52001	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-26	Kevin Kerstetter	kschumacher@tricorinsurance.com	Cuyahoga Falls	Summit County	OH	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	Kevin Kerstetter	kschumacher@tricorinsurance.com	Same	Cuyahoga Falls	Summit County	OH	Russell Masartis	Nancy Wortley	Signed
1413	2023-01-06 15:15	Anonymous (not verified)	199.120.121.97	Jason Gaul	Proprietorship	1088 Ridge Lane Harlan, IA 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.	2023-01-06	Jason Robert Gaul	gauljasonr@gmail.com	Harlan	Shelby	Iowa	Haley Leinen	Scott Leinen	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Robert Gaul	gauljasonr@gmail.com	Self	Harlan	Shelby	Iowa	Haley Leinen	Scott Leinen	Signed
623	2021-08-30 15:03	Anonymous (not verified)	174.198.77.231	Joe Dawson	Proprietorship	1088, Dogwood 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.	2021-08-30	Joe R Dawson	joerdawson@gmail.com	Coon Rapids	IA	United States	Linda Doran	Megan Specht	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Joe R Dawson	joerdawson@gmail.com	Owner	Coon Rapids	IA	United States	Linda Doran	Megan Specht	Signed
2176	2024-04-24 11:12	Anonymous (not verified)	94.188.205.176	Schutters Pest Control Inc.	Limited Liability Company	109 2nd Ave, Suite #2, Carbon Cliff,IL 61239	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-04	Billy Y Schutters	schutterspestcontrol@gmail.com	Bettendorf	Iowa	United States	Aidan Sammon	Kalissa Malin	Signed	(1) The employer does not elect the employers’ liability coverage.	Billy Y Schutters	schutterspestcontrol@gmail.com	Same Person	Carbon Cliff	Rock Island	Illinois	Aidan Sammon	Kalissa Malin	Signed
1203	2022-07-13 09:49	Anonymous (not verified)	69.57.16.37	Travis Trucking	Proprietorship	109 2ND ST, CURLEW, IA 50527	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-13	TODD TRAVIS	toddthefarmet@gmail.com	Curlew	Palo Alto	Iowa	Alex Elbert	Kelsey Elbert	Signed	(1) The employer does not elect the employers’ liability coverage.	Todd Travis	toddthefarmet@gmail.com	Owner/sole propietor	Curlew	Palo Alto	Iowa	Alex Elbert	Kelsey Elbert	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
1519	2023-03-16 09:15	Anonymous (not verified)	94.188.205.176	Frommelt Logging LLC	Limited Liability Company	109 Great River Rd. Holy Cross IA 52053	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-16	Josh Frommelt	jfrommelt1987@gmail.com	Holy Cross	Clayton	Iowa	Staci Frommelt	Mitzi Hoeger	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Frommelt	jfrommelt1987@gmail.com	owner	Holy Cross	Clayton	Iowa	Staci Frommelt	Mitzi Hoeger	Signed
1738	2023-07-11 10:51	Anonymous (not verified)	94.188.207.224	Augustin Santos	Proprietorship	109 Loomis Ave Des Moines, Iowa 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-05	Augustin Santos	deb@piciowa.com	Des Moines	Polk	Iowa	Deb Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Augustin Santos	deb@piciowa.com	self	Des Moines	Polk	Iowa	Deb Stratton	Kelly Denger	Signed
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
1706	2023-06-23 17:32	Anonymous (not verified)	94.188.205.169	pro plumbing and heating llc	Limited Liability Company	109 w market st, po box 205 saint charles ia 50240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	lee douglas kearney	ankenypro@gmail.com	saint charles	madison	iowa	sheila may kearney	madison grace kearney	Signed	(1) The employer does not elect the employers’ liability coverage.	lee d kearney	ankenypro@gmail.com	owner	saint charles	madison	iowa	sheila may kearney	madison grace kearney	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
1045	2022-04-13 09:55	Anonymous (not verified)	192.119.237.126	BARGAIN HOUSE	Proprietorship	11 S FREDERICK AVE, OELWEIN, IA 50662	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-13	RICHARD M. BECKER	SHELBY@CIOIA.COM	HAZLETON	BUCHANAN	IOWA	SHELBY S. WILLIAMS	BOBBIE J. BERGAN	Signed	(1) The employer does not elect the employers’ liability coverage.	RICHARD M. BECKER	SHELBY@CIOIA.COM	OWNER	OELWEIN	FAYETTE	IOWA	SHELBY S. WILLIAMS	BOBBIE J. BERGAN	Signed
2090	2024-03-12 14:16	Anonymous (not verified)	94.188.205.169	Oscar Sosa	Proprietorship	110 E Cherry St 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.	2023-01-01	Oscar Sosa	oscarsosa@live.com	Cherokee	Cherokee	Iowa	Adrian Dominguez	Ronald Halverson	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron Halverson	ron@sppinsurance.com	independent contractor	Cherokee	Cherokee	IA	Oscar Sosa	Ronald Halverson	Signed
282	2020-10-21 07:00	Anonymous (not verified)	98.16.114.26	Fine Cut Lawn Service, LLC	Limited Liability Partnership	110 E Street, SW. P.O. Box 835 Melcher, IA. 50163	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-19	Eric E Benz	eric@finecutwaterscapes.com	Melcher	Marion	IA	Angelia Warner	Allen Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Eric Eugene Benz	eric@finecutlawn.com	same person	Melcher	Marion	IA	Angela Warner	Allen Smith	Signed
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
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
14	2019-12-30 17:22	Anonymous (not verified)	173.20.51.69	Rotten Love LLC	Limited Liability Company	1101 Valentine Drive, Dubuque Iowa 52003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-01-01	john rettenmeier	jrettenmeier@gmail.com	dubuque	Dubuque	iowa	Carolyn Schmid	Joe Rettenmeier	Signed	(1) The employer does not elect the employers’ liability coverage.	Carolyn Schmid	jrettenmeier@gmail.com	owner	Dubuque	Dubuque	iowa	John Rettenmeier	John Rettenmeier	Signed
159	2020-05-18 14:21	Anonymous (not verified)	173.28.28.57	Matthew Klahsen	Proprietorship	1103 Gray Street, Aplington IA 50604	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Matthew Klahsen	cmins_re@mchsi.com	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Klahsen	cmins_re@mchsi.com	Self	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
326	2020-11-25 08:39	Anonymous (not verified)	66.188.136.150	Robert Barbaris	Proprietorship	1104 8th St SE, Cedar Rapids, IA 52401	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-11-25	Robert Barbaris	kschumacher@tricorinsurance.com	Cedar Rapids	Linn	IA	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Barbaris	kschumacher@tricorinsurance.com	Same	Cedar Rapids	Linn	IA	Russell Masartis	Nancy Wortley	Signed
431	2021-03-10 14:41	Anonymous (not verified)	66.188.136.150	Brad Donovan	Proprietorship	1105 N 5th. Springfield, IL 62702	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Brad Donovan	braddonovan40@gmail.com	Springfield	Sangamon	IL	Russell Masartis	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Brad Donovan	braddonovan40@gmail.com	Same	Springfield	Sangamon	IL	Russell Masartis	Shuree Behr	Signed
367	2021-01-21 14:18	Anonymous (not verified)	107.117.168.117	1105 Wade St	Proprietorship	1105 WADE 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.	2021-01-03	Jose J Castillo	Jonathancas782@gmail.com	DES MOINES	IA	United States	Jose gaytan	Ruben lopez	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose J Castillo	Jonathancas782@gmail.com	Owner	DES MOINES	IA	United States	Jose gaytan	Ruben lopez	Signed
1526	2023-03-21 12:24	Anonymous (not verified)	94.188.207.223	Quad Cities Transport Inc	Proprietorship	1106 46th ave Rock Island IL 61201	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-21	Howard Davis	qctranaportinc@gmail.com	East Moline	Rock Island	Illinois	Ricky Oconner	Patrick Watkins	Signed	(1) The employer does not elect the employers’ liability coverage.	Howard Davis	hdenterprisesinc14@gmail.com	Owner	East Moline	Rock Island	Illinois	Patrick Watkins	Ricky Oconner	Signed
1527	2023-03-22 08:35	Anonymous (not verified)	94.188.205.167	Quad Cities Transport Inc	Proprietorship	1106 46th ave Rock Island IL 61201	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-21	Howard Rick Clark Davis	hdenterprisesinc14@gmail.com	East Moline	Rock Island	IL	Patrick Watkins	Ricky Oconner	Signed	(1) The employer does not elect the employers’ liability coverage.	Howard Davis	qctransportinc@gmail.com	Owner	East Moline	Rock Island	Illinois	Ricky Oconner	Patrick Watkins	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
422	2021-03-05 13:53	Anonymous (not verified)	71.39.227.238	Steven Phillips	Proprietorship	1107 Walnut St, Dallas Center, IA 50063	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-06	Steven Phillips	stevep@phillipsassociatesins.net	Linden	Guthrie	Iowa	Abbey Luellen	RoseMary Phillips	Signed	(1) The employer does not elect the employers’ liability coverage.	Steven Phillips	stevep@phillipsassociatesins.net	Self	Linden	Guthrie	Iowa	RoseMary Phillips	Abbey Luellen	Signed
423	2021-03-05 13:55	Anonymous (not verified)	71.39.227.238	RoseMary Phillips	Proprietorship	1107 Walnut St, Dallas Center, IA 50063	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-05	RoseMary Phillips	stevep@phillipsassociatesins.net	Linden	Guthrie	Iowa	Steven Phillips	Abbey Luellen	Signed	(1) The employer does not elect the employers’ liability coverage.	RoseMary Phillips	stevep@phillipsassociatesins.net	Self	Linden	Guthrie	Iowa	Steve Phillips	Abbey Luellen	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
1223	2022-07-22 15:14	Anonymous (not verified)	167.142.255.81	HomeOwner's Helper LLC	Limited Liability Company	111 4th Ave, Underwood, IA 51576	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-22	Bradley W Syndergaard	mrslouie8@yahoo.com	UNDERWOOD	Iowa	United States	Stacy L Louison	Brent C Louison	Signed	(1) The employer does not elect the employers’ liability coverage.	Bradley W Syndergaard	mrslouie8@yahoo.com	Self	UNDERWOOD	Iowa	United States	Stacy L Louison	Brent C Louison	Signed
987	2022-03-20 10:53	Anonymous (not verified)	75.162.173.186	John Greenman Painting	Proprietorship	111 Village Drive 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.	2022-03-20	john greenman	greenmanj55@gmail.com	west des moines	iowa	iowa	Angela Kay Olsem	Peggy Ann Greenman	Signed	(1) The employer does not elect the employers’ liability coverage.	John William Greenman	greenmanj55@gmail.com	owner	west des moines	iowa	iowa	Angela Kay Olsem	Peggy Ann Greenman	Signed
478	2021-04-14 13:18	Anonymous (not verified)	65.103.82.36	Fortress Lock & Key LLC	Proprietorship	1111 w 10th st. 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.	2020-02-12	Paul Dunn	na@gmail.com	Davenport	Scott	IA	Jordan	Rose	Signed	(1) The employer does not elect the employers’ liability coverage.	Paul Dunn	na@gmail.com	Owner	Davenport	Scott	IA	jordan	Rose	Signed
1314	2022-09-19 16:43	Anonymous (not verified)	96.31.1.206	CHARVEL TREJO	Proprietorship	1113 L AVE, MILFORD, IA 51331	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-19	CHARVEL TREJO	LEVRACH@YAHOO.COM	MILFORD	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	CHARVEL TREJO	LEVRACH@YAHOO.COM	SELF	MILFORD	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed
1892	2023-11-02 12:24	Anonymous (not verified)	94.188.205.169	TREJO'S CONSTRUCTION LLC	Limited Liability Company	1113 L 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.	2023-11-02	CHARVEL TREJO	levrach@yahoo.com	MILFORD	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	CHARVEL TREJO	levrach@yahoo.com	SELF	MILFORD	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed
1990	2024-01-16 22:22	Anonymous (not verified)	94.188.205.168	DeltaPro Painting & Remodeling	Limited Liability Company	1115 Nolan Court North Liberty Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-16	Bayron Amador	bayronamador59@gmail.com	North Liberty	IA	Estados Unidos	Claudia Garmendia	Marlon Amador	Signed	(1) The employer does not elect the employers’ liability coverage.	Bayron Amador	bayronamador59@gmail.com	Owner/Employer	North Liberty	IA	Estados Unidos	Claudia Garmendia	Marlon Amador	Signed
1577	2023-04-17 09:58	Anonymous (not verified)	94.188.205.167	Four Leaf LLC	Limited Liability Company	11150 NE 72nd St Bondurant IA 50035	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-17	Eric O'Shea	Fourleaf2021@gmail.com	Bondurant	IA	United States	Lucas Gray	Curt Decker	Signed	(1) The employer does not elect the employers’ liability coverage.	Eric Michael O'Shea	Fourleaf2021@gmail.com	Owner	Bondurant	IA	United States	Lucas Gray	Curt Decker	Signed
2057	2024-02-26 16:17	Anonymous (not verified)	94.188.207.228	Pedro Salazar Trejo	Proprietorship	1116 18th Ave SW Cedar Rapids IA 52402	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-26	Pedro Salazar Trejo	pedrosalazart@icolud.com	Cedar rapids	Linn County	IA	Carlos Izaguirre	Omar Trejo	Signed	(1) The employer does not elect the employers’ liability coverage.	Martiniano Germán Maldonado	maldonadomartiniano675@gmail.com	Employee	Cedar rapids	Linn County	Iowa	Carlos Izaguirre	Omar Trejo	Signed
1398	2022-12-21 22:02	Anonymous (not verified)	24.149.20.131	B's Lawn Care	Limited Liability Company	1118 Rainbow Drive, Cedar Falls, Iowa 50613, 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.	2022-12-21	Brandon Ballenger	lawncare.bee@gmail.com	Cedar Falls	Iowa	United States	Katie Ballenger	Tyler Ballenger	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandon Ballenger	lawncare.bee@gmail.com	Owner/Operator	Cedar Falls	Iowa	United States	Katie Ballenger	Tyler Ballenger	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
91	2020-03-13 15:51	Anonymous (not verified)	173.24.190.134	Small Town RV, LLC	Limited Liability Company	112 Miller 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.	2020-03-09	Heath Sabin	sales@smalltownrv.com	Mallard	Palo Alto	Iowa	Dave Walters	Candie Clark	Signed	(1) The employer does not elect the employers’ liability coverage.	Heath Sabin	sales@smalltownrv.com	Member of LLC	Mallard	Palo Alto	Iowa	Dave Walters	Candie Clark	Signed
92	2020-03-13 15:53	Anonymous (not verified)	173.24.190.134	Tammy Sabin	Limited Liability Company	112 Miller 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.	2020-03-09	Tammy Sabin	sales@smalltownrv.com	Mallard	Palo Alto	Iowa	Dave Walters	Candie Clark	Signed	(1) The employer does not elect the employers’ liability coverage.	Tammy Sabin	sales@smalltownrv.com	Member of LLC	Mallard	Palo Alto	Iowa	Dave Walters	Candie Clark	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
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
1434	2023-01-31 07:12	Anonymous (not verified)	162.233.75.173	abc	Proprietorship	1122	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-31	Brian Yurko	byurko714@gmail.com	Cedar Falls	Black Hawk	Iowa	pete	re pete	Signed	(1) The employer does not elect the employers’ liability coverage.	LHE	byurko@leafhome.com	contractor	Deerfield Beach	Florida	United States	pete	re pete	Signed
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
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
640	2021-09-16 22:43	Anonymous (not verified)	97.125.255.204	Morgan Group LLC	Limited Liability Company	1124 7th St. West Des Moines, Iowa 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-16	Mackinley Charles Morgan	Morgangroupllc@gmail.com	West Des Moines	Polk	Iowa	Deborah Renee Morgan	Mark Steven Morgan	Signed	(1) The employer does not elect the employers’ liability coverage.	Mackinley Charles Morgan	Morgangroupllc@gmail.com	Owner of company	West Des Moines	Polk	Iowa	Deborah Renee Morgan	Mark Steven Morgan	Signed
145	2020-04-30 16:09	Anonymous (not verified)	173.191.206.253	Mark Knapp	Proprietorship	11244 Linden 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.	2020-04-30	Mark A Knapp	mlmlknapp@iowatelecom.net	Linden	Iowa	United States	Phil Hesseltine	Kathy Hesseltine	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Knapp	mlmlknapp@iowatelecom.net	self	Linden	Iowa	United States	Phil Hesseltine	Kathy Hesseltine	Signed
1670	2023-05-30 17:07	Anonymous (not verified)	94.188.207.226	Davis&Viteri LLC	Limited Liability Company	1125 Florida ave apt 519 Ames Iowa 50014	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-30	Christopher Viteri	davisviteri17@gmail.com	Johnston	Polk	Iowa	Labron davis	Marshalle Coleman	Signed	(1) The employer does not elect the employers’ liability coverage.	Marshalle coleman	marshalle.coleman@yahoo.con	Friend	Ames	Story	Iowa	Marshalle coleman	Labron davis	Signed
16	2019-12-31 08:54	Anonymous (not verified)	70.184.208.208	J & D Transportation	Proprietorship	1125 Lew Ross Road Council Bluffs, IA 51501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-12-31	Clarence Cecil Stogdill	jack@jdmmtrucking.com	Council Bluffs	Iowa	United States	Mickey Jerome Stogdill	Laurie Jo Stogdill	Signed	(1) The employer does not elect the employers’ liability coverage.	Clarence Cecil Stogdill	jack@jdmmtrucking.com	owner-same person	Council Bluffs	Iowa	United States	Mickey Jerome Stogdill	Laurie Jo Stogdill	Signed
432	2021-03-11 18:17	Anonymous (not verified)	99.196.90.45	A-Z Tree Service	Proprietorship	1128 W 124th St S	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-11	Daniel Keeney	dansatoztreeservice@gmail.com	Colfax	Jasper	Iowa	David Short	Brandon Vriezlaar	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Keeney	dansatoztreeservice@gmail.com	Sole Proprietor	Colfax	Jasper	Iowa	David Short	Brandon Vriezlaar	Signed
280	2020-10-20 08:02	Anonymous (not verified)	98.23.12.154	Peters Painting	Proprietorship	11286 290th Manning IA 51455	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-20	gregory peters	rangreg@windstream.net	Manning	Carroll	IA	Amy Hansen	Todd Stadtlander	Signed	(1) The employer does not elect the employers’ liability coverage.	Gregory Peters	rangreg@windstream.net	self	Manning	Carroll	IA	Amy Hansen	Todd Stadtlander	Signed
904	2022-02-08 08:11	Anonymous (not verified)	173.23.180.117	Dawg House Renovation	Limited Liability Company	113 Allen St Waterloo Iowa 50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-08	Steve Sprague	dawghouse729@gmail.com	Waterloo	Black Hawk	Iowa	Paula Sprague	Stewart Sprague	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Sprague	dawghouse729@Gmail.Com	Self	Waterloo	Black Hawk	Iowa	Paula Sprague	Stewart Sprague	Signed
1137	2022-06-01 09:05	Anonymous (not verified)	63.170.122.111	sanchez framing construction llc	Limited Liability Company	113 e a st west liberty, ia 52776	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Cindy Sanchez	sanchezframingconst.llc@gmail.com	west liberty	muscatine	iowa	patricia verdines	yajahira estrada	Signed	(1) The employer does not elect the employers’ liability coverage.	n/a	sanchezframingconst.llc@gmail.com	n/a	n/a	n/a	n/a	n/a	n/a	Signed
100	2020-03-24 15:46	Anonymous (not verified)	216.51.130.87	Lake City Electric, LLC	Limited Liability Company	113 E Main Street, Lake City, IA 51449	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-24	Lonnie R. Daisy	lcelectric@iowatelecom.net	Lake City	Calhoun	IOWA	Sheryl Lynch	Karen Prebeck	Signed	(1) The employer does not elect the employers’ liability coverage.	Lonnie R. Daisy	lcelectric@iowatelecom.net	self	Lake City	Calhoun	IOWA	Sheryl Lynch	Karen Prebeck	Signed
1680	2023-06-06 12:08	Anonymous (not verified)	94.188.205.168	Sipac Drywall	Proprietorship	1130 Columbia St, Waterloo, IA 50703	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-06	Jennifer Sipac	jenniferyoung164@gmail.com	Waterloo	Black Hawk	Iowa	Augie Ferguson	Wendy Phillips	Signed	(1) The employer does not elect the employers’ liability coverage.	Jennifer Sipac	jenniferyoung164@gmail.com	Owner	Waterloo	Black Hawk	Iowa	Augie Ferguson	Wendy Phillips	Signed
1373	2022-11-16 12:28	Anonymous (not verified)	173.22.187.22	MCDONALD'S LAWN & TREE SERVICES	Proprietorship	1130 N. 4 AVE. W. 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.	2022-11-16	Roger McDonald	RABBITMCDONALD@HOTMAIL.COM	Newton	IA	United States	Patricia McMahon	Bryan McMahon	Signed	(1) The employer does not elect the employers’ liability coverage.	Roger McDonald	RABBITMCDONALD@HOTMAIL.COM	Self	Newton	IA	United States	Patricia McMahon	Bryan McMahon	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
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
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
655	2021-09-24 15:28	Anonymous (not verified)	67.212.111.166	S Miller Painting LLC	Limited Liability Company	1135 Barnett Drive, 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.	2021-09-24	Steven David Miller	stevendm24@hotmail.com	Cedar Falls	Black Hawk	Iowa	Steve Koger	Mark Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Cory Allen koger	coryspainting@gmail.com	Self	Cedar Falls	Black Hawk	Iowa	Steve Koger	Mark Miller	Signed
286	2020-10-21 18:32	Anonymous (not verified)	173.218.73.44	Bilyeu Underground LLC	Limited Liability Company	1136 W. Irene Ct. Nixa, MO 65714	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-21	Daniel Bilyeu	danielbilyeu@gmail.com	Nixa	Christian	Missouri	Gary George Bilyeu	Chad Anthony Charles	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Bilyeu	danielbilyeu@gmail.com	Owner	Nixa	Christian	Missouri	Gary George Bilyeu	Chad Anthony Charles	Signed
287	2020-10-21 18:35	Anonymous (not verified)	173.218.73.44	Bilyeu Underground LLC	Limited Liability Company	1136 W. Irene Ct. Nixa, MO 65714	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-21	Gary George Bilyeu	garygb1990@gmail.com	Sparta	Christian	Missouri	Daniel Bilyeu	Chad Anthony Charles	Signed	(1) The employer does not elect the employers’ liability coverage.	Gary George Bilyeu	garygb1990@gmail.com	Owner	Sparta	Christian	Missouri	Chad Anthony Charles	Daniel Bilyeu	Signed
288	2020-10-21 18:36	Anonymous (not verified)	173.218.73.44	Bilyeu Underground LLC	Limited Liability Company	1136 W. Irene Ct. Nixa, MO 65714	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-21	Chad Anthony Charles	y4ardgn0m3r@gmail.com	Nixa	Christian	Missouri	Gary George Bilyeu	Daniel Bilyeu	Signed	(1) The employer does not elect the employers’ liability coverage.	Chad Anthony Charles	y4ardgn0m3r@gmail.com	Owner	Nixa	Christian	Missouri	Gary George Bilyeu	Daniel Bilyeu	Signed
263	2020-09-21 09:49	Anonymous (not verified)	66.188.136.150	Scott Kunz	Proprietorship	114 10th Ave. Camanche, IA 52730	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-15	Scott Kunz	kschumacher@tricorinsurance.com	Camanche	Clinton	IA	Russell Masartis	Angie Olds	Signed	(1) The employer does not elect the employers’ liability coverage.	Scott Kunz	kschumacher@tricorinsurance.com	Same	Camanche	Clinton	IA	Russell Masartis	Angie Olds	Signed
1429	2023-01-25 13:43	Anonymous (not verified)	136.35.255.41	J&D Renovations	Proprietorship	114 2nd St. Carbon Cliff, IL 61239	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Donald Lane	jdrenovations309@gmail.com	Carbon Cliff, IL	Rock Island County	Illinois	Jordan Nisiewicz	Cody Dunbar	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Jordan Loyd	Cody Dubar	Signed
1465	2023-02-17 15:05	Anonymous (not verified)	94.188.207.228	Big roofing	Proprietorship	114 sw 58th dr	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-17	David Christiansen	Mattc@bigroofing515.com	Des moines	Polk	IA	STEVE BIEGHLER	Jordan walkup	Signed	(1) The employer does not elect the employers’ liability coverage.	Matt christiansen	Mattc@bigroofing515.com	Self	Des moines	County	Ia	Steve bieghler	Jordan walkup	Signed
2016	2024-02-01 09:20	Anonymous (not verified)	94.188.207.225	Imperium Outdoor Solutions	Proprietorship	114 W Clanton St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-01	Austin Beener	abeener033@gmail.com	St Charles	IA	United States	Austin Beener	Austin Beener	Signed	(1) The employer does not elect the employers’ liability coverage.	Austin Beener	abeener033@gmail.com	Operator	St Charles	IA	United States	Austin Beener	Austin Beener	Signed
2034	2024-02-07 11:58	Anonymous (not verified)	94.188.207.230	Bryce Abbott	Proprietorship	114 West Linn Street, Lone Tree, IA 52755	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-31	Bryce David Abbott	bryceabbott86@gmail.com	Lone Tree	Johnson	United States	Dixie Abbott	Andy Abbott	Signed	(1) The employer does not elect the employers’ liability coverage.	Bryce Abbott	bryceabbott86@gmail.com	Self	Lonetree	Johnson	IA	Dixie Abbott	Andy Abbott	Signed
1116	2022-05-17 21:41	Anonymous (not verified)	75.162.182.172	Hinds Metal Designs LLC	Limited Liability Company	11409 Dakota St, 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.	2022-05-18	Brad Hinds	bahinds@msn.com	Norwalk	Iowa	Iowa	Trevor Masten	Travis Masten	Signed	(1) The employer does not elect the employers’ liability coverage.	Carlene Hinds	carlene4082@msn.com	Self	Norwalk	Iowa	Iowa	Trevor Masten	Travis Masten	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
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
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
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
1967	2023-12-27 13:28	Anonymous (not verified)	94.188.207.225	Marvin Gingrich	Proprietorship	114641 Chariot Rd Elgin Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-25	Marvin Gingerich	darrele@ciains.biz	Elgin	Fayette	Iowa	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Marvin Gingerich	darrele@ciaisn.biz	Self	Elgin	Fayette	Iowa	Chris Fye	Darrel Elsbernd	Signed
410	2021-02-19 09:23	Anonymous (not verified)	166.181.84.153	Nikolai Charikov	Proprietorship	115 6th St NW	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-19	Nikolai Andre Charikov	nikolaicharikov@gmail.com	Mitchellville	Polk	Iowa	Tyler Charikov	Mile Hufford	Signed	(1) The employer does not elect the employers’ liability coverage.	Nikolai Charikov	nikolaicharikov@gmail.com	Self	Mitchellville	Polk	Iowa	Tyler Charikov	Mile Hufford	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
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
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
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
1232	2022-07-28 18:27	Anonymous (not verified)	50.83.189.149	Eagle Construction Co LLC	Limited Liability Company	1150 county line rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-28	Carlos Flores	eagleconstruciontco.865@gmail.com	Des Moines	Warren	Iowa	Morgan Conrard	Ronika Htu	Signed	(1) The employer does not elect the employers’ liability coverage.	Carlos Flores	eagleconstruciontco.865@gmail.com	Owner	Des Moines	Warren	IA	Morgan Conrard	Ronika Htu	Signed
924	2022-02-17 13:02	Anonymous (not verified)	208.81.192.69	Wapsie Valley Construction, LLC	Limited Liability Company	1154 Dennison Ave., Fairbank, IA 50629	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-17	Henry O. Miller	accounting@robertseddy.com	Fairbank	Buchanan	Iowa	Brian C. Eddy	Samantha J. Stelter	Signed	(1) The employer does not elect the employers’ liability coverage.	Merle Miller	accounting@robertseddy.com	Same person	Fairbank	Buchanan	Iowa	Brian C. Eddy	Samantha J. Stelter	Signed
925	2022-02-17 13:07	Anonymous (not verified)	208.81.192.69	Wapsie Valley Construction, LLC	Limited Liability Company	1154 Dennison Ave., Fairbank, IA 50629	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-17	Chester H. Borntrager	accounting@robertseddy.com	Hazleton	Buchanan	Iowa	Brian C. Eddy	Samantha J. Stelter	Signed	(1) The employer does not elect the employers’ liability coverage.	Merle Miller	accounting@robertseddy.com	Same person	Fairbank	Buchanan	Iowa	Brian C. Eddy	Samantha J. Stelter	Signed
920	2022-02-17 10:15	Anonymous (not verified)	208.81.192.69	Wapsie Valley Construction, LLC	Limited Liability Company	1154 Dennison Avenue, Fairbank, IA 50629	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-17	Merle B. Miller	accounting@robertseddy.com	Fairbank	Buchanan	Iowa	Brian C. Eddy	Samantha J. Stelter	Signed	(1) The employer does not elect the employers’ liability coverage.	Merle B. Miller	accounting@robertseddy.com	Same person	Fairbank	Buchanan	Iowa	Brian C. Eddy	Samantha J. Stelter	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
2021	2024-02-02 10:12	Anonymous (not verified)	94.188.207.227	JUSIC ENTERPRISES LLC DBA MJS TREE SERVICE	Limited Liability Company	11619 NW 106TH AVE GRANGER, IA 50109	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-02	MERSUDIN JUSIC	MERSO.JUSIC@GMAIL.COM	GRANGER	POLK COUNTY	IOWA	RICHARD BALES	ZACHARY SMITH	Signed	(1) The employer does not elect the employers’ liability coverage.	MERSUDIN JUSIC	MERSO.JUSIC@GMAIL.COM	MEMBER OWNER	GRANGER	POLK	IOWA	RICH BALES	ZACHARY SMITH	Signed
1742	2023-07-12 12:43	Anonymous (not verified)	94.188.207.228	Old Glory Home Improvements LLC	Limited Liability Company	117 E Church st, Panora, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-12	Laden Binjiman McDonald	mcdonaldladen@gmail.com	Waukee	Dallas	Iowa	Tina McDonald	Matt McDonald	Signed	(1) The employer does not elect the employers’ liability coverage.	Northwest Registered Agent	bmartin@frannet.com	Employer	Panora	Guthrie	Iowa	Tina McDonald	Matt McDonald	Signed
2037	2024-02-07 22:06	Anonymous (not verified)	94.188.205.174	Harold wotton snow and lawn service	Proprietorship	117 east kimball st hancock Iowa 51536	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-04	Harold wotton	hwotton79@icloud.com	Hancock Iowa	United States	Iowa	Crystal Wogomon	Brody Weber	Signed	(1) The employer does not elect the employers’ liability coverage.	Harold wotton	hwotton79@icloud.com	Owner	Hancock	United States	Iowa	Crystal Wogomon	Brody Weber	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
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
611	2021-08-19 15:23	Anonymous (not verified)	97.125.53.119	Rogelio Lopez Casillas	Proprietorship	1175 Office Park Road Apt 109 WDM, Iowa 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-21	Rogelio Lopez Casillas	deb@piciowa.com	West Des Moines	Polk	Iowa	Debra Stratton	Kelly K Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Rogelio Lopez Casillas	deb@piciowa.com	subcontractor	West Des Moines	Polk	Iowa	Debra Stratton	Kelly K Denger	Signed
762	2021-11-22 09:23	Anonymous (not verified)	71.34.169.117	Oscar Lopez	Proprietorship	1175 Office Park Road Apt 109 West Des Moines, Iowa 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-15	Oscar Lopez	deb@piciowa.com	WDM	Polk	ia	Debra Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Oscar Lopez	deb@piciowa.com	self	WDM	Polk	IA	Debra Stratton	Kelly Denger	Signed
2112	2024-03-22 08:22	Anonymous (not verified)	94.188.205.174	WR TREE SERVICES	Limited Liability Company	1176 highway 9 Lansing 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.	2024-03-22	Wesley Adam Remund	wesleyadamremund@gmail.com	Lansing	Allamakee	Iowa	JENNIFER K Harris	Stefan M Remund	Signed	(1) The employer does not elect the employers’ liability coverage.	Wesley Adam Remund	wesleyadamremund@gmail.com	OWNER	Lansing	Allamakee	Iowa	Jennifer K Harris	Stefan M Remund	Signed
779	2021-12-06 10:43	Anonymous (not verified)	172.83.21.144	Munn Enterprises LLC	Limited Liability Company	118 14th Avenue 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.	2021-12-06	Douglas A Munn	munnent1328@gmail.com	Clear lake	IA	IA	Troy Thomas Munn	Marjorie Marie Munn	Signed	(1) The employer does not elect the employers’ liability coverage.	Troy Munn	Troy@munnentllc.com	Owner	Clear Lake	Cerro Gordo	Iowa	Troy Thomas Munn	Marjorie Marie Munn	Signed
780	2021-12-06 10:45	Anonymous (not verified)	172.83.21.144	Munn Enterprises LLC	Limited Liability Company	118 14th Avenue 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.	2021-12-06	Troy T Munn	Troy@munnentllc.con	Clear lake	Cerro Gordo	Iowa	Douglas A Munn	Marjorie Marie Munn	Signed	(1) The employer does not elect the employers’ liability coverage.	Troy Thomas Munn	troy@munnentllc.com	Same	Clear Lake	Cerro Gordo	Iowa	Douglas A Munn	Marjorie Marie Munn	Signed
412	2021-02-23 14:23	Anonymous (not verified)	205.185.135.176	Jeffrey Meyer	Proprietorship	118 1st St SE New Albin IA 52160	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-23	Jeffrey Meyer	meyertimberservices@gmail.com	New Albin	Allamakee	Iowa	Michael Klug	Kayla Snitker	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Klug	mike@aibme.com	Insurance Agent	Caledonia	Houston	Minnesota	Jeffrey Meyer	Kayla Snitker	Signed
1017	2022-03-29 14:53	Anonymous (not verified)	208.81.192.69	Wapsie Valley Insulation, LLC	Limited Liability Company	1180 110th Street Fairbank, IA 50629	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-29	Lester Kauffman	bookkeeping@robertseddy.com	Fairbank	Buchanan	Iowa	Sarah Van Buren	Julie Ohl	Signed	(1) The employer does not elect the employers’ liability coverage.	Lester Kauffman	bookeeping@robertseddy.com	Same	Fairbank	Buchanan	Iowa	Sarah Van Buren	Julie Ohl	Signed
1065	2022-04-21 16:26	Anonymous (not verified)	172.58.84.198	Royal Flooring	Limited Liability Company	11801 Hickman Rd Urbandale Iowa 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.	2022-04-21	Alondra Canedo Orta	alondracanedo34@gmail.com	Des Moines	Polk county	Iowa	Alondra Canedo	Marvin Bonilla	Signed	(1) The employer does not elect the employers’ liability coverage.	Royal Flooring	Workorders@shoproyalflooring.com	Employee	Des Moines	Polk county	Iowa	Alondra Canedo	Marvin Bonilla	Signed
686	2021-10-20 18:43	Anonymous (not verified)	173.27.196.168	Royal Flooring	Proprietorship	11801 Hickman Rd Urbandale, IA 50323 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.	2021-10-20	Joel Cisneros	auroraramos476@gmail.com	Des Moines	Polk county	Iowa	Aurora Cisneros	Maria Arroyo	Signed	(1) The employer does not elect the employers’ liability coverage.	Royal Flooring	cisnerostile476@gmail.com	Employee	Clive	Dallas	Iowa	Aurora Cisneros	Maria Arroyo	Signed
2166	2024-04-20 13:38	Anonymous (not verified)	94.188.205.175	Cedar Valley Seamless, LLC	Limited Liability Company	1184 215th St, Jesup, IA 50648	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-20	Andrew Richard Trumbauer	cedarvalleyseamlessllc@gmail.com	Jesup	Buchanan	Iowa	James William Masteller	Andrew William Hamilton	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Richard Trumbauer	cedarvalleyseamlessllc@gmail.com	Owner/Operator	Jesup	Buchanan	Iowa	James William Masteller	Andrew William Hamilton	Signed
230	2020-08-13 16:59	Anonymous (not verified)	174.217.21.76	Aaron Gilbert	Proprietorship	11864 W 125th St S, Runnells, IA 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.	2020-08-13	Aaron Michael Gilbert	gilbertinpc@msn.com	Runnells	Jasper	Iowa	Bob Coluzzi	Mitch Coluzzi	Signed	(1) The employer does not elect the employers’ liability coverage.	Aaron Michael Gilbert	gilbertinpc@msn.com	Same person	Runnells	Jasper	Iowa	Bob Coluzzi	Mitch Coluzzi	Signed
1496	2023-03-06 11:24	Anonymous (not verified)	94.188.207.227	Carrillo Drywall, LLC	Limited Liability Company	119 Marsh St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-06	Yesenia Carrillo	yesecarrillo84@gmail.com	Waterloo	IA	United States	Rene Carrillo Jr	Martha Basurto	Signed	(1) The employer does not elect the employers’ liability coverage.	Kyle Hildman	kyleh@sinnottagency.com	Insurance Agent	Waterloo	IA	United States	Rene Carrillo Jr	Martha Basurto	Signed
1082	2022-04-29 12:28	Anonymous (not verified)	75.162.101.109	Jodi Trewet	Proprietorship	11920 NW 114th Ln Granger, IA 50109	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-29	Jodi Trewet	jtrewet@yahoo.com	Granger	IA	United States	Mark Trewet	Tyler Trewet	Signed	(1) The employer does not elect the employers’ liability coverage.	Jodi Trewet	jtrewet@yahoo.com	Same	Granger	Polk	IA	Mark Trewet	Tyler Trewet	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
1489	2023-02-28 16:06	Anonymous (not verified)	94.188.207.228	Nate's Tractor LLC	Limited Liability Company	11939 birch Ave Riceville, IA 50466	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-28	Nathan Fox	nate@natestractor.com	Riceville	Howard	Iowa	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Nathan Fox	nate@natestractor.com	Member	Riceville	Howard	Iowa	Chris Fye	Darrel Elsbernd	Signed
1712	2023-06-26 20:33	Anonymous (not verified)	94.188.205.167	Eastern Iowa Overhead Door	Proprietorship	120 N Eliza 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.	2023-06-26	Tim Chapin	easterniadoor@gmail.com	Maquoketa	IA	United States	Carri Lee Waack	Wendy Marie Zaruba	Signed	(1) The employer does not elect the employers’ liability coverage.	Tim Chapin	easterniadoor@gmail.com	Owner	Maquoketa	Jackson	United States	Carri Lee Waack	Wendy Marie Zaruba	Signed
1221	2022-07-21 13:40	Anonymous (not verified)	129.222.3.107	Barkers Handyman Express	Proprietorship	120 S Mill St Gilman, IA 50106	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-22	Devin Levi Barker	devinbarker91@gmail.com	Gilman	Marshall	Iowa	Emily Anne Barker	Lloyd Owen Barker Jr.	Signed	(1) The employer does not elect the employers’ liability coverage.	Devin Levi Barker	devinbarker91@gmail.com	Owner	Gilman	Marshall	IA	Emily Anne Barker	Lloyd Owen Barker Jr.	Signed
706	2021-11-02 11:45	Anonymous (not verified)	50.82.130.211	Kierstyn Anest	Proprietorship	1200 Parriott Street, Aplington IA 50604	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-25	Kierstyn Anest	cmins_re@mchsi.com	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Kerstyn Anest	cmins_re@mchsi.com	Self	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
54	2020-02-06 14:18	Anonymous (not verified)	173.28.28.57	Dale Hansman dba Klinkenborg Hansmann Law Office	Proprietorship	1201 Hwy 57, Parkersburg, IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-14	Dale Hansmann	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Dale Hansmann	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
1928	2023-11-29 21:48	Anonymous (not verified)	94.188.205.168	Iowa Evolution Constuction	Partnership	1203 Bluegrass 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.	2022-01-01	Claudia Rodriguez	claudia.rodriguez.213@gmail.com	CEDAR FALLS	IA	United States	Guillermo Nunez	Blanca rodriguez	Signed	(1) The employer does not elect the employers’ liability coverage.	Claudia Rodriguez	claudia.rodriguez.213@gmail.com	Owner	CEDAR FALLS	IA	United States	Guillermo Nunez	Blanca Rodriguez	Signed
1744	2023-07-13 13:52	Anonymous (not verified)	94.188.205.176	T-Rex Construction LLC	Limited Liability Company	1203 Bluegrass Circle Unit 4 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.	2023-07-12	Claudia Rodriguez De Nunez	t.rexbigbiz@gmail.com	CEDAR FALLS	IA	United States	Ana Chavez	Alicia Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Guillermo Nunez	claudia.rodriguez.213@gmail.com	Spouse	CEDAR FALLS	IA	United States	Alicia Garcia	Ana Chavez	Signed
558	2021-07-07 13:35	Anonymous (not verified)	66.188.136.150	Austin Kalfus Sr.	Proprietorship	1203 Poppy Ave. Pensacola, FL 32507	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-07	Austin Kalfus Sr.	kschumacher@tricorinsurance.com	Pensacola	Escambia	FL	Mitch Kemp	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Austin Kalfus Sr.	kschumacher@tricorinsurance.com	Same	Pensacola	Escambia	FL	Mitch Kemp	Shuree Behr	Signed
388	2021-02-10 11:48	Anonymous (not verified)	97.125.123.32	Pro Bull Painting LLC	Limited Liability Company	1204 sampson st Des Moines IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-10	Eduardo Garcia Becerril	probullpainting1@gmail.com	Des Moines	Polk	Iowa	Juan Carlos Garcia	Rigoberto Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Eduardo Garcia	Probullpainting1@gmail.com	Owner	Des moines	Polk	Iowa	Juan Carlos Garcia	Rigoberto Garcia	Signed
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
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
333	2020-12-05 08:57	Anonymous (not verified)	173.25.143.97	Groen Pediatric Consulting	Limited Liability Company	1206 NE 31ST ST 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.	2021-01-01	Amy Groen	dramygroen@yahoo.com	Ankeny	Iowa	United States	Daniel Martin	Anita Anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Amy Groen	dramygroen@yahoo.com	self	Ankeny	Iowa	United States	Kay Martin	Priscilla Putzier	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
178	2020-06-08 13:51	Anonymous (not verified)	173.21.16.200	Daniel Mullanack	Limited Liability Company	1208 Franklin 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.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2020-06-08	daniel mullanack	mullanackbuilders@mediacombb.net	buffalo	scott	iowa	brandon brooks	amy carlson	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	linda mullanack	mullanackbuilders@mediacombb.net	office manager	buffalo	scott	iowa	brandon brooks	amy carlson	Signed
1782	2023-08-04 08:04	Anonymous (not verified)	94.188.207.229	Matt Larson Construction	Limited Liability Company	1208 Hazel St. Pella, IA 50219	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-04	Matthew Mark Larson	larson-m@hotmail.com	Pella	Marion	IA	Brian Huddle	Jon E. Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Jon E. Miller	stmarypella@iowatelecom.net	Parish Secretary	Pella	IOWA	United States	Brian Huddle	Jon E. Miller	Signed
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
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
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
1115	2022-05-17 19:36	Anonymous (not verified)	173.23.50.204	Delgado Electrical Services	Limited Liability Company	1210 Creston Ave Des Moines, Iowa 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-17	Cesar Delgado	delgado.electrical@gmail.com	Des Moines	Polk	Iowa	Mike Willet	Alex Segovia	Signed	(1) The employer does not elect the employers’ liability coverage.	Cesar Delgado	cesar.delgado31@yahoo.com	Owner	Des Moines	Polk	Iowa	Mike Willet	Alex Segovia	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
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
1793	2023-08-09 15:23	Anonymous (not verified)	94.188.205.174	Cesar estuardo marroquin gonzalez	Proprietorship	1212 David st 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.	2023-08-09	Cesar estuardo marroquin gonzalez	marroquincesar1788@gmail.com	1212 David st waterloo iowa	Black haw	Iowa	Sonia Gomez	Sonia Gomez	Signed	(1) The employer does not elect the employers’ liability coverage.	Cesar estuardo marroquin gonzalez	marroquincesar1788@gmail.com	Patrón	1212 David st waterloo iowa	Black hawn	Iowa	Sonia Gomez	Sonia Gomez	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
1381	2022-11-30 20:41	Anonymous (not verified)	97.125.145.12	Central Iowa Outdoor Services	Proprietorship	1213 Parkhill Dr.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-30	Keegan Eggers	CentralIowaServices1@gmail.com	Norwalk	Iowa	United States	Stephanie Eggers	Kelsie Eggers	Signed	(1) The employer does not elect the employers’ liability coverage.	Keegan Eggers	CentralIowaServices1@gmail.com	Owner	Norwalk	Iowa	United States	Stephanie Eggers	Kelsie Eggers	Signed
615	2021-08-20 16:22	Anonymous (not verified)	50.81.152.147	CPIA Home Specialists LLC	Limited Liability Company	1214 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.	2021-08-20	Melvin Benitez	Benitezmelvin0@gmail.com	Des Moines	Iowa	United States	Salvador Benitez	Zoila Benitez	Signed	(1) The employer does not elect the employers’ liability coverage.	Melvin Benitez	Benitezmelvin0@gmail.com	Owner	Des Moines	Iowa	United States	Salvador Benitez	Zoila Benitez	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
1286	2022-08-26 09:09	Anonymous (not verified)	97.125.43.203	Daniel Lugo	Proprietorship	1217 Harold Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-24	Daniel Lugo	deb@piciowa.com	Des Mpines	Polk	IA	Debra Stratton	Martin Pinon	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel LUgo	deb@piciowa.com	self	Des Moines	Polk	Iowa	Debra Stratton	Martin Pinon	Signed
2163	2024-04-19 08:53	Anonymous (not verified)	94.188.205.174	George Petree	Proprietorship	1219 N 7th 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.	2024-04-19	George Harlan Petree	g_petree@hotmail.com	Burlington	Des Moines	Iowa	Cheryl Ross	Larry Rheinschmidt	Signed	(1) The employer does not elect the employers’ liability coverage.	George Harlan Petree	g_petree@hotmail.com	owner	Burlington	Des Moines	Iowa	Cheryl Ross	Larry Rheinschmidt	Signed
1602	2023-04-25 20:10	Anonymous (not verified)	94.188.207.228	Miguel D.	Limited Liability Company	1221 22nd st des moines ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-21	Miguel Duron	Duron6478@gmail.com	Des moines	Polk	Ia	Uziel martinez	Cesar jaz	Signed	(1) The employer does not elect the employers’ liability coverage.	Miguel Duron	Diron6478@gmail.com	Self	Des moines	Polk	Iowa	Uziel Martinez	Cesar jaz	Signed
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
2187	2024-04-29 08:30	Anonymous (not verified)	94.188.207.226	Fran Stonework LLC	Limited Liability Company	1222 E Seneca Ave Apt 7, Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-29	Francisco Rodriguez Rios	panchito941@icloud.com	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Francisco Rodriguez Rios	panchito941@icloud.com	Self	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed
359	2021-01-12 11:37	Anonymous (not verified)	173.29.116.114	Quad City Restorations	Limited Liability Company	1225 E River Drive, Suite 320, Davenport, IA 52803	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-12	Christopher Rogers	chris@quadcityrestorations.com	DAVENPORT	Scott	IA	Lea Luquire	Lisa Rubio	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher Rogers	chris@quadcityrestorations.com	Owner / Employer	DAVENPORT	Scott	IA	Lea Luquire	Lisa Rubio	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
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
102	2020-03-25 11:23	Anonymous (not verified)	206.72.14.249	Brandi Wehr	Proprietorship	123 E Marion St, Sigourney, IA 52591	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-25	Brandi Jo Wehr	brndwehr54@hotmail.com	Sigourney	Keokuk	Iowa	Amber Kephart	Mary Beth Knipfer	Signed	(1) The employer does not elect the employers’ liability coverage.	Chelsea Voss	chelsea@grimmrealestate.com	Agent	North English	Iowa	Iowa	Amber Kephart	Mary Beth Knipfer	Signed
89	2020-03-13 12:41	Anonymous (not verified)	216.96.113.16	B’s Sweet Treats	Proprietorship	123 E Marion St. Sigourney IA 52591	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-13	Brandi Wehr	brndwehr54@hotmail.com	Sigourney	Keokuk	IA	Brandi	Brandi	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandi Wehr	brndwehr54@hotmail.com	Same	Sigourney	Keokuk	IA	Brandi	Brandi	Signed
445	2021-03-23 12:34	Anonymous (not verified)	172.58.84.232	XD PAINTING	Limited Liability Company	1233 Herold Ave Des Moines Iowa 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-23	Daniel Alcaraz Suarez	xdpainting@gmail.com	Des Moines	Polk county	Iowa	Anthony Maland	Marcus Ross	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Alcaraz Suarez	xdpainting@gmail.com	None	Des Moines	Polk county	Iowa	Anthony maland	Marcus Ross	Signed
1901	2023-11-10 07:08	Anonymous (not verified)	94.188.205.174	Elegance Exteriors	Limited Liability Company	1236 11th Ave N	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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.	2023-11-10	Tre Trotter	Tre@eleganceexteriors.com	Fort Dodge	Webster	Iowa	Kyle Grell	Raenell Richardson	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Hiscox Inc.	contact@hiscox.com	None	Atlanta	Fulton	Georgia	Raenell Richardson	Kyle Grell	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
1605	2023-04-26 09:48	Anonymous (not verified)	94.188.207.229	Double Barrell Construction	Proprietorship	1237 S 52nd St, #804, West Des Moines, IA 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-26	Braedyn Baylor	bbaylor66@gmail.com	West Des Moines	Polk	IA	Peggy Toft	Rick Thompson	Signed	(1) The employer does not elect the employers’ liability coverage.	Braedyn Baylor	bbaylor66@gmail.com	Owner	West Des Moines	Polk	IA	Peggy Toft	Rick Thompson	Signed
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
825	2022-01-06 21:02	Anonymous (not verified)	174.213.145.18	Two Brothers Tile llc	Proprietorship	1244 72nd St Windsor heights ia 50324	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-06	Senahid Mujkanovic	xbosanacbax17@gmail.com	Windsor Heights	IA	United States	Ramiza kadric	Senad mujkanovic	Signed	(1) The employer does not elect the employers’ liability coverage.	Senahid Mujkanovic	xbosanacbax17@gmail.com	Owner	Windsor Heights	IA	United States	Ramiza kadric	Senad mujkanovic	Signed
1168	2022-06-23 12:57	Anonymous (not verified)	74.84.106.106	dora valadez	Proprietorship	1244 e 32 nd 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.	2022-06-23	dora valadez	towens@smartind.com	Des Moines	Polk	Iowa	Tina Owens	Kim Owens	Signed	(1) The employer does not elect the employers’ liability coverage.	dora valadez	towens@smartind.com	self	Des Moines	Polk	Iowa	Tina Owens	Kim Owens	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
1152	2022-06-13 13:05	Anonymous (not verified)	70.96.153.153	Tyler Ankney	Proprietorship	1250 A 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.	2022-06-13	Tyler Ankney	tyler.a@optionsexteriors.com	Marion	Linn County	Iowa	Charlotte Rasmussen	Austin Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Tyler Ankney	tyler.a@optionsexteriors.com	Owner	Marion	Linn County	Iowa	Charlotte Rasmussen	Austin Miller	Signed
1513	2023-03-13 06:54	Anonymous (not verified)	94.188.205.169	Tyler Ankney	Proprietorship	1250 A Avenue, Marion, IA 52302, 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.	2023-03-13	Tyler Ankney	T_james55@ahoo.com	Marion	Linn County	Iowa	Jordan Nisiewicz	Steve Gisler	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Jordan Loyd	Steve Gisler	Signed
1987	2024-01-16 12:35	Anonymous (not verified)	94.188.207.229	Wasabi urbandale LLc	Limited Liability Company	12509 Townsend Ava, Urbandale, IA 50323	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-16	Wen Zheng	jenna18841002@hotmail.com	Urbandale	Dallas	Iowa	Jie Li	Yingna Zheng	Signed	(1) The employer does not elect the employers’ liability coverage.	Wen Zheng	jenna18841002@hotmail.com	Owner	Urbandale	Dallas	Iowas	Jie Li	Yingna zheng	Signed
586	2021-07-26 08:37	Anonymous (not verified)	71.7.62.131	Jeffrey Knoot	Proprietorship	1251 Illinois Dr. Knoxville IA, 50138-8862	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-26	Jeffrey Jon Knoot	opsisdental@gmail.com	Knoxville	Marion	Iowa	Sharon Kay Spriggs	Lisa Michelle Dudley	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeffrey Jon Knoot	opsisdental@gmail.com	self	Knoxville	Marion	Iowa	Sharon Kay Spriggs	Lisa Michelle Dudley	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
1348	2022-10-28 10:19	Anonymous (not verified)	208.38.230.122	HALSEY'S HOME IMPROVEMENTS, LLC	Limited Liability Company	126 SYCAMORE LANE, RIVERDALE, IOWA 52722	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-28	MONTY RAY HALSEY	crickstic@gmail.com	RIVERDALE	SCOTT	IA	DARRELL MACHALEK JR.	MATTHEW DAVISON	Signed	(1) The employer does not elect the employers’ liability coverage.	MONTY HALSEY	crickstic@gmail.com	SELF	RIVERDALE	SCOTT	IA	DARRELL MACHALEK JR.	MATTHEW DAVISON	Signed
1722	2023-07-06 10:57	Anonymous (not verified)	94.188.205.169	Brother’s Handyman Services LLC	Proprietorship	1270 A Avenue, Marion, IA 52302, 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.	2023-07-06	Tyler Dahl	handybros39@gmail.com	Marion, IA	Linn County	Iowa	Jordan Nisiewicz	Charles Woods	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City, MO	Johnson	Missouri	Charles Woods	Jordan Loyd	Signed
2131	2024-04-02 10:28	Anonymous (not verified)	94.188.205.168	Driskell Spray, LLC	Limited Liability Company	1279 300th Ave Sidney, IA 51652	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-22	Jamie Driskell	driskell216@gmail.com	Sidney	Fremont	Iowa	Melinda Goy	Rhett Goy	Signed	(1) The employer does not elect the employers’ liability coverage.	Jamie Driskell	driskell216@gmail.com	owner	Sidney	Fremont	Iowa	Melinda Goy	Rhett Goy	Signed
1018	2022-03-29 15:00	Anonymous (not verified)	97.125.143.50	Modified Originals of Winterset	Limited Liability Company	128 S 3rd Ave, Winterset, IA 50273	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-29	Daniel Maiers	Modifiedoriginals.winterset@gmail.com	Winterset	Iowa	Iowa	Mark Haddinger	Josh Williams	Signed	(1) The employer does not elect the employers’ liability coverage.	Dan Maiers	Modifiedoriginals.winterset@gmail.com	Self	Winterset	Iowa	Iowa	Mark Haddinger	Josh Williamson	Signed
345	2020-12-29 09:20	Anonymous (not verified)	173.18.16.129	Eben-Ezer Concrete Services	Proprietorship	1283 dixon 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.	2020-12-29	Saul Artero	Artro50313@yahoo.com	Des Moines	Polk	Iowa	Jen Lambert	Lesa Reeves	Signed	(1) The employer does not elect the employers’ liability coverage.	Saul Artero	Artro50313@yahoo.com	owner	des moines	Polk	Iowa	Jen Lambert	Lesa Reeves	Signed
2174	2024-04-24 08:22	Anonymous (not verified)	94.188.205.175	White's Floorcovering	Proprietorship	129 Hillcrest Dr. Biggsville, IL 61418	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-22	Ron White	hntwhite@frontiernet.net	Biggsville	Henderson	Illinois	Cheryl Ross	Larry Rheinschmidt	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron White	hntwhite@frontiernet.net	owner	Biggsville	Henderson	Illinois	Cheryl Ross	Larry Rheinschmidt	Signed
2154	2024-04-16 08:05	Anonymous (not verified)	94.188.207.226	Lanz Pork Inc	Proprietorship	12905 N 1050th Road, Macomb, IL 61455	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-02	Andrew M Riggins	kellylanz1967@gmail.com	Macomb	IL	United States	Barb Coker	Scott Caspall	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew M Riggins	kellylanz1967@gmail.com	Self	Macomb	IL	United States	Barb Coker	Scott Caspall	Signed
2155	2024-04-16 08:13	Anonymous (not verified)	94.188.207.225	Andrew M Riggins	Proprietorship	12905 N 1050th Road, Macomb, IL 61455	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-02	Andrew M Riggins	kellylanz1967@gmail.com	Macomb	IL	United States	Barb Coker	Scott Caspall	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew M Riggins	kellylanz1967@gmail.com	Self	Macomb	IL	United States	Barb Coker	Scott Caspall	Signed
526	2021-05-19 09:36	Anonymous (not verified)	66.188.136.150	John Robinson	Proprietorship	12990 E 48th Ave. Denver, CO 80239	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-18	John Robinson	kschumacher@tricorinsurance.com	Denver	Denver	CO	Mitch Kemp	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	John Robinson	kschumacher@tricorinsurance.com	Same	Denver	Denver	CO	Mitch Kemp	Shuree Behr	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
530	2021-05-25 08:30	Anonymous (not verified)	159.242.43.24	FoxTrot Foods, LLC	Limited Liability Company	13-15 S Federal Ave, Mason City IA 50401	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-25	Melissa Fabian	melissafabian@yahoo.com	Mason City	Cerro Gordo	Iowa	Jenny McIntyre	Dan Wunschel	Signed	(1) The employer does not elect the employers’ liability coverage.	Melissa Fabian	melissafabian@yahoo.com	Owner-Member	Mason City	Cerro Gordo	Iowa	Jenny McIntyre	Dan Wunschel	Signed
909	2022-02-10 08:03	Anonymous (not verified)	166.181.83.242	Kim Hildebrand	Proprietorship	130 Sabrina cir 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.	2022-02-07	Kimberly Kay Hildebrand	kimregenold@yahoo.com	Waterloo	Blackhawk	Iowa	Darrin Hildebrand	Stephanie Nerison	Signed	(1) The employer does not elect the employers’ liability coverage.	Kimberly Kay Hildebrand	kimregenold@yahoo.com	Self	Waterloo	Blackhawk	Iowa	Darrin Hildebrand	Stephanie Nerison	Signed
339	2020-12-15 15:23	Anonymous (not verified)	74.221.46.229	CORRECTIONVILLE GOLF CLUB INC	Limited Liability Company	1300 HACKBERRY STREET CORRECTIONVILLE IA 51016	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-12-15	KATIE EDWARDS	KEDWARDS@FNBCORRECTIONVILLE.COM	CORRECTIONVILLE	WOODBURY	IA	CANDACE JACOBSON	AMBER HANSEN	Signed	(1) The employer does not elect the employers’ liability coverage.	KIM MEBIUS	KMEBIUS@FNBCORRECTIONVILLE.COM	PRESIDENT	CORRECTIONVILLE	WOODBURY	IA	CANDACE JACOBSON	AMBER HANSEN	Signed
1059	2022-04-19 15:06	Anonymous (not verified)	64.186.23.83	CORRECTIONVILL GOLF CLUB, INC	Limited Liability Company	1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	NICK HEATH	dogboy3485@yahoo.com	CORRECTIONVILLE	WOODBURY	IOWA	CANDACE JACOBSON	AMBER HANSEN	Signed	(1) The employer does not elect the employers’ liability coverage.	KATIE EDWARDS	kedwards@fnbcorrectionville.com	SEC/TREASURER	CORRECTIONVILLE	WOODBURY	IOWA	CANDACE JACOBSON	AMBER HANSEN	Signed
1060	2022-04-19 15:08	Anonymous (not verified)	64.186.23.83	CORRECTIONVILLE GOLF CLUB, INC	Limited Liability Company	1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	ADAM KELLY	dslkraz@gmail.com	CORRECTIONVILLE	WOOD	IWOA	CANDACE	AMBER HANSEN	Signed	(1) The employer does not elect the employers’ liability coverage.	KATIE EDWARDS	kedwards@fnbcorrectionville.com	SEC/TREASURER	CORRECTIONVILLE	WOODBURY	IOWA	CANDACE JACOBSON	AMBER HANSEN	Signed
1691	2023-06-14 19:20	Anonymous (not verified)	94.188.205.174	Amazing Painting LLC	Limited Liability Company	1301 Boyd Street, 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.	2023-06-14	Evan Michael Regenwether	Evan@amazingpaintingia.com	Des Moines	Polk	Iowa	Austin Matthew Regenwether	Abby Marie Regenwether	Signed	(1) The employer does not elect the employers’ liability coverage.	Evan Michael Regenwether	evan@amaingpaintingia.com	Owner	Des Moines	Polk	Iowa	Austin Matthew Regenwether	Abby Regenwether	Signed
648	2021-09-21 10:03	Anonymous (not verified)	97.125.32.164	Manuel Morales	Proprietorship	1302 13th St Des Moines, Iowa 50314	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-15	Manuel Morales	deb@piciowa.com	Des Moines	Polk	Iowa	Deb Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Manuel Morales	deb@picowa.com	subcontractor	Des Moines	Polk	Iowa	Deb Stratton	Kelly Denger	Signed
106	2020-03-31 10:42	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.	2020-03-31	Bart Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Janice Henningsen	Louise Helmke	Signed	(1) The employer does not elect the employers’ liability coverage.	Bart Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Janice Henningsen	Louise Helmke	Signed
107	2020-03-31 10:47	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.	2020-03-31	James Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Janice Henningsen	Louise Helmke	Signed	(1) The employer does not elect the employers’ liability coverage.	James Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Janice Henningsen	Louise Helmke	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
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
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
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
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
472	2021-04-13 10:58	Anonymous (not verified)	65.103.82.36	Scrap And More	Proprietorship	1303 W Linn St. Marshalltown, IA. 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.	2019-05-01	Travis Bachman	na@yahoo.com	marshalltown	marshall	IA	sarah	Tami	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Bachman	na@yahoo.com	owner	marshalltown	marsahll	IA	sara	tami	Signed
1389	2022-12-11 12:36	Anonymous (not verified)	24.149.1.5	Project Fix It LLC	Limited Liability Company	1303 Washington Street Cedar Falls 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.	2022-12-12	Adam L Reiter	adam.reiter@projectfixit.net	Cedar Falls	IA	United States	Jennifer Reiter	Logan Reiter	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Project Fix It	adam.reiter@projectfixit.net	Owner	Cedar Falls	IA	United States	Jennifer Reiter	Logan Reiter	Signed
389	2021-02-10 13:59	Anonymous (not verified)	173.24.190.134	Shamrock Lanes, LLC	Limited Liability Company	1304 Broadway, PO Box 304, Emmetsburg IA 50536	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-03	Cindy Flannegan	cindylou1964@hotmail.com	Emmetsburg	Palo Alto	Iowa	Michael Flannegan	Laura Sidles	Signed	(1) The employer does not elect the employers’ liability coverage.	Cindy Flannegan	cindylou1964@hotmail.com	Member of LLC	Emmetsburg	Palo Alto	Iowa	Michael Flannegan	Laura Sidles	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
783	2021-12-08 10:25	Anonymous (not verified)	173.31.148.43	Nick Larsen	Proprietorship	1305 7th 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.	2021-12-08	Nick Larsen	larsennick77@gmail.com	Milford	Dickinson	IA	JOSEPH THOMAS LORING	Kristine Ann Walker	Signed	(1) The employer does not elect the employers’ liability coverage.	Nick Larsen	joel@walkerinsuranceia.com	Self	Milford	Dickinson	IA	JOSEPH THOMAS LORING	Kristine Ann Walker	Signed
1248	2022-08-09 11:29	Anonymous (not verified)	166.181.82.131	Kelly Kellogg	Proprietorship	1305 N 1st st apt 16	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-09	Kelly	Kkell0223@gmail.com	Indianola	Warren	Iowa	Kelly Kellogg	Amy Kellogg	Signed	(1) The employer does not elect the employers’ liability coverage.	Royal flooring	workorders@shoproyalflooring.com	Employee	Urbandale	Polk	Iowa	Amy	Kelly	Signed
1249	2022-08-09 14:14	Anonymous (not verified)	166.181.82.131	Kelly Kellogg	Proprietorship	1305 N 1st st apt 16	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-09	Kelly Kellogg	Kkell0223@gmail.com	Indianola	Warren	Iowa	Kelly Kellogg	Amy Kellogg	Signed	(1) The employer does not elect the employers’ liability coverage.	Kelly's Flooring	Kkell0223@gmail.com	Myself	1305 N 1st st apt 16	Warren	Iowa	Kelly Kellogg	Amy Kellogg	Signed
742	2021-11-11 15:14	Anonymous (not verified)	72.13.16.172	JACOB WESLEY JOHNSON	Proprietorship	1306 BAXTER 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.	2019-11-18	JACOB WESLEY JOHNSON	dave@allseasonstrucking.com	FAIRBANK	BUCHANAN	IA	Dave Neuwohner	BEN MOYER	Signed	(1) The employer does not elect the employers’ liability coverage.	JACOB WESLEY JOHNSON	dave@allseasonstrucking.com	PRESIDENT	FAIRBANK	BUCHANAN	IA	Dave Neuwohner	BEN MOYER	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
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
1902	2023-11-10 08:45	Anonymous (not verified)	94.188.207.226	Huff Construction LLC	Limited Liability Company	1309 Business 30 Sw, Mount Vernon, IA 52314	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-10	Jason Huff	huff.jasonm@gmail.com	Mount Vernon	IA	United States	Katie Huff	Van Huff	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Huff	huff.jasonm@gmail.com	Owner	Mount Vernon	IA	United States	Katie Huff	Van Huff	Signed
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
1066	2022-04-22 11:17	Anonymous (not verified)	50.83.107.151	Delos Steward	Proprietorship	1310 w Main Street 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.	2022-04-22	Delos Lyle Steward	LDSPlastering2020@gmail.com	Marshalltown	Marshall	Iowa	Chris Hart	Jody Steward	Signed	(1) The employer does not elect the employers’ liability coverage.	LDS Plastering	ldsplastering2020@gmail.com	Owner	Marshalltown	Marshall	Iowa	Chris Hart	Jody Steward	Signed
589	2021-07-28 16:09	Anonymous (not verified)	97.125.35.240	Sotero Alonso Calderon Velasquez	Proprietorship	1312 Idaho St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-26	Sotero Alonso Calderon Velazquez	deb@piciowa.com	Des Moines	Polk	Iowa	Debra Stratton	Martin Pinon	Signed	(1) The employer does not elect the employers’ liability coverage.	Sotero Alonso Calderon Velazquez	deb@piciowa.com	subcontractor	Des MOines	Polk	Iowa	Debra Stratton	Martin Pinon	Signed
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
468	2021-04-12 14:54	Anonymous (not verified)	173.27.224.230	PCI Turf LLC	Limited Liability Company	1313 N Grant St. Knoxville, IA 50138	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-12	Ryan Trout	rtrout22@yahoo.com	Knoxville	Marion	Iowa	Joseph Durham	Carson Peterson	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Trout	pci.turf@yahoo.com	Self- owner/operator	Knoxville	Marion	Iowa	Joseph Durham	Carson Peterson	Signed
758	2021-11-19 15:12	Anonymous (not verified)	184.80.177.137	Upper Room, LLC	Limited Liability Company	1314 9th St SE - 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.	2021-11-19	Keith McCarraher	jheims@english-insurance.com	Dyersville	Dubuque	Iowa	Derrick Parsons	Joyce Heims	Signed	(1) The employer does not elect the employers’ liability coverage.	Joyce Heims	jheims@english-insurance.com	agent	Dyersville	Dubuque	Iowa	Derrick Parsons	Joyce Heims	Signed
757	2021-11-19 15:11	Anonymous (not verified)	184.80.177.137	Upper Room, LLC	Limited Liability Company	1314 9th St SE -Dyersville, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-19	DeAnne M McCarraher	jheims@english-insurance.com	Dyersville	Dubuque	Iowa	Derrick Parsons	Joyce Heims	Signed	(1) The employer does not elect the employers’ liability coverage.	Joyce Heims	jheims@english-insurance.com	agent	Dyersville, IA	Dubuque	Iowa	Derrick Parsons	Joyce Heims	Signed
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
887	2022-02-03 14:05	Anonymous (not verified)	173.27.49.231	Jade Mallicoat coaching	Limited Liability Company	1318 se linn 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.	2022-02-03	Jade Mallicoat	jade.mallicoat@gmail.com	Boone	Boone	Iowa	Cord Anderson	Mike Anderson	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jade mallicoat	jade.mallicoat@gmail.com	Myself	Boone	Boone	Iowa	Cord Anderson	Mike Anderson	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
430	2021-03-10 13:01	Anonymous (not verified)	192.30.185.142	Trey LaGois Construction	Proprietorship	132 W Cedar St, Hinton, IA 51024	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Trey LaGois	treylagois2015@gmail.com	Hinton	Plymouth	IA	Katie Jenks	Nate Blaeser	Signed	(1) The employer does not elect the employers’ liability coverage.	Trey LaGois	treylagois2015@gmail.com	Owner	Hinton	Plymouth	IA	Katie Jenks	Nate Blaeser	Signed
1885	2023-10-29 08:05	Anonymous (not verified)	94.188.207.223	MB Radon Services	Limited Liability Company	13206 State Hwy 2, Lamoni, Iowa, 50140	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-29	Kyle Ramaeker	raymaker83@gmail.com	LAMONI	IA	United States	Adam Boge	Lance Webster	Signed	(1) The employer does not elect the employers’ liability coverage.	Kyle Ramaeker	raymaker83@gmail.com	Owner/Operator	LAMONI	IA	United States	Adam Boge	Lance Webster	Signed
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
436	2021-03-16 13:37	Anonymous (not verified)	141.193.221.33	Custom Applicationz	Partnership	13220 Hwy S70 Plano, IA 52581	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-16	Zebulun Joiner	joinerconst@gmail.com	Plano	Appanoose	IA	Danielle Joiner	Zebulun Joiner	Signed	(1) The employer does not elect the employers’ liability coverage.	Danielle Joiner	joinerconst@gmail.com	Self/Wife of Partner	Plano	Appanoose	IA	Zebulun Joiner	Danielle Joiner	Signed
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
990	2022-03-21 15:18	Anonymous (not verified)	174.192.80.32	Chris Binns	Proprietorship	1324 Grand Ave Davenport, IA 52803	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-21	Christ Binns	christophersbinns@gmail.com	Davenpory	Scott	IA	Adam Coleman	Rose Snyder	Signed	(1) The employer does not elect the employers’ liability coverage.	Chris Binns	christophersbinns@gmail.com	Same	Davenport	Scott	IA	Adam Coleman	Rose Snyder	Signed
992	2022-03-21 19:42	Anonymous (not verified)	174.192.66.11	Christopher Binns	Proprietorship	1324 Grand Ave, Davenport, IA 52803	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-21	Christopher Binns	christophersbinns@gmail.com	Davenport	Scott	IA	Adam Coleman	Rose Snyder	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher Binns	christophersbinns@gmail.com	same	Davenport	Scott	IA	Adam Coleman	Rose Snyder	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
474	2021-04-13 12:09	Anonymous (not verified)	65.103.82.36	Helfrich Construction	Proprietorship	1327 Garnet St. Burlington 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.	2019-04-29	Tad Helfrich	littlet20012001@yahoo.com	Burlington	Des Moines	IA	Teresa Helfrich	Ron Helfrich	Signed	(1) The employer does not elect the employers’ liability coverage.	Tad Helfrich	littlet20012001@yahoo.com	owner	Burlington	Des Moines	IA	Teresa Helfrich	Ron Helfrich	Signed
1477	2023-02-23 11:45	Anonymous (not verified)	94.188.205.166	Earl Woods DBA Solar Solutions	Proprietorship	1328 42nd St Des Moines IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-23	Earl Woods	solarsolutions_1@msn.com	Des Moines	Polk	Iowa	Terrie Woods	Tracy Day	Signed	(1) The employer does not elect the employers’ liability coverage.	Earl Woods	solarsolutions_1@msn.com	wife	Des Moines	Polk	IA	Terrie Woods	Tracy Day	Signed
829	2022-01-11 11:03	Anonymous (not verified)	173.22.78.156	Marr Arnold Planning, LLC	Limited Liability Company	1328 California Ave, Ames, IA 50014	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-11	Summer Marr	summer@marrarnoldplanning.com	Ames	Story	IA	Beth Skluzacek	Kris Evans	Signed	(1) The employer does not elect the employers’ liability coverage.	Summer Marr	summer@marrarnoldplanning.com	owner	Ames	Story	IA	Beth Skluzacek	Kris Evans	Signed
828	2022-01-11 10:34	Anonymous (not verified)	74.215.151.63	Marr Arnold Planning	Limited Liability Company	1328 California Ave. Ames Iowa 50014	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-11	Sarah Arnold	sarahkarnold@gmail.com	Cincinnati	Hamilton	Ohio	April Humphreys	Amy Burns	Signed	(1) The employer does not elect the employers’ liability coverage.	Sarah Arnold	sarah@marrarnoldplanning.com	Self	Cincinnati	Hamilton	Ohio	Amy Burns	April Humphreys	Signed
1828	2023-09-06 14:43	Anonymous (not verified)	94.188.205.177	Des Moines Smart Solutions LLC.	Proprietorship	1329 56th st, Des Moines, IA 50311, United States	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-06	Denzel Colocho	alejandro_colcho@yahoo.com	Des Moines, IA	Polk	Iowa	Jordan Nisiewicz	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	MO	Jordan Loyd	Charles Wood	Signed
1821	2023-08-29 10:11	Anonymous (not verified)	94.188.205.169	Des Moines Smart Solutions LLC	Limited Liability Company	1329 56th St., Des Moines, IA 50311	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-29	Denzel Colocho	alejandro_colocho@yahoo.com	Des Moines	Polk	Iowa	Steve Webb	Austin Kelderman	Signed	(1) The employer does not elect the employers’ liability coverage.	Des Moines Smart Solutions LLC	alejandro_colocho@yahoo.com	Owner	Des Moines	Polk	Iowa	Steve Webb	Austin Kelderman	Signed
1011	2022-03-28 10:25	Anonymous (not verified)	207.199.231.172	Brian Carmer	Proprietorship	133 S Iowa Ave, 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.	2022-03-28	Brian Carmer	b_carmer@yahoo.com	Ottumwa	Wapello	Iowa	James Anderson	Ashley Bryan	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Carmer	B_Carmer@yahoo.com	Self	Ottumwa	Wapello	Iowa	James Anderson	Ashley Bryan	Signed
1825	2023-08-30 11:16	Anonymous (not verified)	94.188.207.225	Quad City Glass	Proprietorship	1330 N Harrison St. Davenport, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-30	Jacob Brown	quadcityglass@gmail.com	Davenport	Scott	IOWA	na	na	Signed	(1) The employer does not elect the employers’ liability coverage.	Quad City Glass	Quadcityglass@gmail.com	employee	Davenport	Scott	IOWA	na	na	Signed
1432	2023-01-25 16:52	Anonymous (not verified)	174.228.33.48	Thermal Tight Insulators	Proprietorship	1331 Linden Road	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-25	Shawn Carter	steelershawn@gmail.com	Harlan	Iowa	United States	Barbara Carter	McKenzie carter	Signed	(1) The employer does not elect the employers’ liability coverage.	Shawn Carter	steelershawn@gmail.com	Self	Harlan	Iowa	United States	Barbara Carter	McKenzie carter	Signed
1992	2024-01-18 21:51	Anonymous (not verified)	94.188.205.175	NB Tile	Proprietorship	13310 NE 112th 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.	2024-01-18	Niles Michael James Bailey	NBtiledesign@gmail.com	Maxwell	IA	United States	Kevin Orr	Sydney Paustian	Signed	(1) The employer does not elect the employers’ liability coverage.	Niles Michael James Bailey	NBtiledesign@gmail.com	Owner	Mawell	Polk	Iowa	Kevin Orr	Sydney Paustian	Signed
74	2020-02-24 15:00	Anonymous (not verified)	97.64.133.18	Sky Roofing LLC	Partnership	1332 Idaho St., Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-01	Ramiro Jurado Gomez	Liberty21424@gmail.com	Des Moines	Polk	IA	Valerie Cramer	David Murray	Signed	(1) The employer does not elect the employers’ liability coverage.	Valerie Cramer	cramerlaw@halousa.com	Attorney	Des Moines	Polk	Iowa	David Murray	Sara McGinnis	Signed
75	2020-02-24 15:03	Anonymous (not verified)	97.64.133.18	Sky Roofing LLC	Partnership	1332 Idaho St., Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-01	Ramiro Jurado Bucio	Liberty21424@gmail.com	des moines	Polk	Iowa	Valerie Cramer	David Murray	Signed	(1) The employer does not elect the employers’ liability coverage.	Valerie Cramer	cramerlaw@halousa.com	Attorney	Des Moines	Polk	Iowa	David Murray	Sara McGinnis	Signed
76	2020-02-24 15:05	Anonymous (not verified)	97.64.133.18	Sky Roofing	Partnership	1332 Idaho St., Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-01	Angel Jurado	Liberty21424@gmail.com	des moines	Polk	Iowa	Valerie Cramer	David Murray	Signed	(1) The employer does not elect the employers’ liability coverage.	Cramer Law PLC	cramerlaw@halousa.com	Attorney	Polk	Polk	Iowa	Sara Mc Ginnis	David Murray	Signed
77	2020-02-24 15:07	Anonymous (not verified)	97.64.133.18	Sky Roofing LLC	Partnership	1332 Idaho St., Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-01	Victor Jurado	Liberty21424@gmail.com	des moines	Polk	Iowa	David Murray	Valerie Cramer	Signed	(1) The employer does not elect the employers’ liability coverage.	Cramer Law PLC	Liberty21424@gmail.com	Attorney	DES MOINES	POlk	Iowa	David Murray	Sara McGinnis	Signed
1963	2023-12-18 14:45	Anonymous (not verified)	94.188.207.227	Elite Excavation Services	Limited Liability Company	13335 Amber Rd X44 Anamosa Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-18	Dalton Starn	eliteexcavationservices97@gmail.com	Anamosa	Jones	Iowa	Chase miller	Nathan Decker	Signed	(1) The employer does not elect the employers’ liability coverage.	Dalton Starn	eliteexcavationservices97@gmail.com	Owner	Anamosa	Jones	Iowa	Chase miller	Nathan decker	Signed
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
1001	2022-03-23 10:37	Anonymous (not verified)	104.201.100.158	Joel Jacobsen	Proprietorship	1337 S 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.	2022-03-23	Joel Jacobsen	jjacobsen@phillipsstafford.com	Adel	Iowa	United States	Luke Peterson	Luke van Roekel	Signed	(1) The employer does not elect the employers’ liability coverage.	Joel Jacobsen	jjacobsen@phillipsstafford.com	Self	Adel	Iowa	United States	Luke Peterson	Luke Van Roekel	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
750	2021-11-16 12:34	Anonymous (not verified)	172.58.83.130	Austin Carlson	Proprietorship	1341 iron city avenue atalissa 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.	2021-11-16	Austin Carlson	toppeakconstruction@gmail.com	Atalissa	Muscating	Iowa	Jordan Nisiewicz	Sam Apponey	Signed	(1) The employer does not elect the employers’ liability coverage.	Jorden Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Jackson	Missouri	Jordan Nisiewicz	Sam Apponey	Signed
279	2020-10-19 08:02	Anonymous (not verified)	66.188.136.150	Keith McNair	Proprietorship	13436 Silver Brook Dr. Pickerington, OH 43147	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-16	Keith McNair	kschumacher@tricorinsurance.com	Pickerington	Fairfield	OH	Nancy Wortley	Russell Masartis	Signed	(1) The employer does not elect the employers’ liability coverage.	Keith McNair	kschumacher@tricorinsurance.com	Same	Pickerington	Fairfield	OH	Nancy Wortley	Russell Masartis	Signed
540	2021-06-08 21:40	Anonymous (not verified)	50.83.39.243	Brightland Appraisal Group	Limited Liability Company	1348 Rolling Glen Dr. 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.	2021-06-08	Eric Lamp	eric.lamp@brightlandappraisal.com	Marion	Linn	Iowa	Sarah Lamp	Linda Lamp	Signed	(1) The employer does not elect the employers’ liability coverage.	Eric Allen Lamp	eric.lamp@brightlandappraisal.com	Self	Marion	Linn	Iowa	Sarah Lamp	Linda Lamp	Signed
303	2020-10-31 13:11	Anonymous (not verified)	173.17.230.149	Absolute Construction	Limited Liability Partnership	135 main street, 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.	2020-10-31	James Nelson	jamesnelson1983@gmail.com	Carlisle	Warren	Iowa	Joe Simpson	Alex Vanderbeek	Signed	(1) The employer does not elect the employers’ liability coverage.	James Nelson	jamesnelson1983@gmail.com	self	Carlisle	Warren	Iowa	Joe Simpson	Alex Vanderbeek	Signed
1022	2022-03-30 15:08	Anonymous (not verified)	216.51.227.123	Elite Business Cleaning	Limited Liability Company	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.	2022-03-30	rogelio morales ortega	info@elitebusinesscleaning.com	iowa city	johnson	Iowa	alma rosa ortega	john Spencer	Signed	(1) The employer does not elect the employers’ liability coverage.	Elite Business Cleaning	info@elitebusinesscleaning.com	Ownerr	iowa city	johnson	iowa	Alma Rosa Ortega	John Spender	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
2001	2024-01-26 10:41	Anonymous (not verified)	94.188.207.225	4 Sons Splicing & Activation	Proprietorship	13510 W Brazos Bend Dr, Needville, TX 77461-9525	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-26	John Kevin Steil	foursons1990@steil.org	Needville	Ft. Bend	Texas	Dennis Reeves Oliver	Stephanie Ranae Oliver	Signed	(1) The employer does not elect the employers’ liability coverage.	Helen Frances Steil	foursons1990@steil.org	Spouse	Needville	Ft. Bend	Texas	Dennis Reeves Oliver	Stephanie Ranae Oliver	Signed
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
551	2021-06-29 09:18	Anonymous (not verified)	72.168.160.90	BERNARD WATERBECK	Limited Liability Company	1353 280TH STREET, GARWIN, IOWA 50632	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-06-29	BERNARD WATERBECK	garwinacres2012@hotmail.com	GARWIN	TAMA	IOWA	DEAN KELLER	CESAR MARROQUIN	Signed	(1) The employer does not elect the employers’ liability coverage.	BERNARD WATERBECK	garwinacres2012@hotmail.com	SAME PERSON	GARWIN	TAMA	IOWA	DEAN KELLER	CESAR MARROQUIN	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
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
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
690	2021-10-26 14:23	Anonymous (not verified)	65.144.174.26	Santiago Rojas	Proprietorship	1359 22nd st 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.	2021-10-26	Santiago Rojas	rojassr09@gmail.com	Des Moines	Polk	Iowa	David Rojas	Beatriz Hernandez	Signed	(1) The employer does not elect the employers’ liability coverage.	Santiago Rojas	rojassr09@gmail.com	Owner	Des Moines	Polk	Iowa	David Rojas	Beatriz Hernandez	Signed
2055	2024-02-23 14:54	Anonymous (not verified)	94.188.207.224	Neil Vonnahme	Proprietorship	13628 220th St., Arcadia, Iowa, 51430	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-20	Neil Vonnahme	neilvonnahme@gmail.com	Arcadia	Carroll	Iowa	Kyle Klein	Brenda Klein	Signed	(1) The employer does not elect the employers’ liability coverage.	Neil Vonnahme	neilvonnahme@gmail.com	Self	Arcadia	Carroll	Iowa	Kyle Klein	Brenda Klein	Signed
469	2021-04-12 16:49	Anonymous (not verified)	65.103.82.36	Stice Construction	Proprietorship	13723 140th st W	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-07-22	Alex Stice	Astice17@hotmail.com	Taylor Ridge	Rock Island	IL	Ashley Stice	JIm Stice	Signed	(1) The employer does not elect the employers’ liability coverage.	Alex Stice	astice17@hotmail.com	self	taylor ridge	rock island	il	Ashley stice	Jim Stice	Signed
2186	2024-04-28 11:12	Anonymous (not verified)	94.188.205.168	John Martin	Proprietorship	1378 60th avenue Blue Grass 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.	2024-04-28	John D Martin	martinflooring@netzero.com	Blue Grass	Muscatine	Iowa	John D Martin	John D Martin	Signed	(1) The employer does not elect the employers’ liability coverage.	John D Martin	martinflooring@netzero.com	Owner	Blue Grass	Muscatine	Iowa	John D Martin	John D Martin	Signed
1915	2023-11-21 04:06	Anonymous (not verified)	94.188.207.225	Advanced Foam Systems	Limited Liability Company	1378 Midway Ave Tripoli IA 50676	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-18	Randy Block	advancedfoamsystems@yahoo.com	Tripoli	Bremer	Iowa	Linda Block	Brady Block	Signed	(1) The employer does not elect the employers’ liability coverage.	Randy Block	advancedfoamsystems@yahoo.com	Me	Tripoli	Bremer	Iowa	Linda block	Brady block	Signed
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
490	2021-04-20 14:06	Anonymous (not verified)	173.18.16.129	frey construction	Limited Liability Company	1388 205th 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.	2021-04-20	Dana Frey	dingaf37@yahoo.com	Creston	Union	Iowa	Lesa Reeves	Kelly Coluzzi	Signed	(1) The employer does not elect the employers’ liability coverage.	Dana Frey	dingaf37@yahoo.com	owner	Creston	Union	Iowa	Lesa Reeves	Kelly Coluzzi	Signed
1998	2024-01-25 16:18	Anonymous (not verified)	94.188.205.168	Faith and Trust Soulutions LLC	Limited Liability Company	139 37th Street NE Suite # 2	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Marie Moore	faithandtrustsoulutionsllc@gmail.com	Cedar Rapids	Iowa	United States	Arthur Barbine	Arthur Barbine	Signed	(1) The employer does not elect the employers’ liability coverage.	Arthur Barbine	faithandtrustsoulutionsllc@gmail.com	Friend	Cedar Rapids	Iowa	United States	Arthur Barbine	Arthur Barbine	Signed
1781	2023-08-03 21:23	Anonymous (not verified)	94.188.205.166	Ron Peiffer Machine	Limited Liability Company	139 S 1st St Harpers Ferry, Ia 52146	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Ron Peiffer	ron@rpeiffer.com	Harpers Ferry	Allamakee	Iowa	Marie Burington	Cassie Bakke	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron Peiffer	ron@rpeiffer.com	myself- SOLE PROPRIETOR	Harpers Ferry	Allamakee	Iowa	Marie Burington	Cassie Bakke	Signed
1057	2022-04-18 12:53	Anonymous (not verified)	204.16.59.10	Iowa’s Gutter Specialist LLC	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.	2022-04-18	Dustin Halverson	dh42312695@gmail.com	Hampton	IA	United States	Heather Halverson	Michael Halverson	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin Halverson	dh42312695@gmail.com	Owner	Hampton	IA	United States	Heather Marie Halverson	Michael Alexander Halverson	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
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
124	2020-04-16 12:07	Anonymous (not verified)	96.3.180.122	Gold Rush, LLC	Limited Liability Company	1395 130TH ST	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-16	Jay Christopher Morrow	jcmorrow2@hotmail.com	WAYLAND	Henry	IAUS	chad mitchell	Jonathan Mitchell	Signed	(1) The employer does not elect the employers’ liability coverage.	Gold Rush, LLC	jcmorrow2@gmail.com	Self	WAYLAND	Henry	IAUS	chad mitchell	Jonathan Mitchell	Signed
189	2020-06-16 16:24	Anonymous (not verified)	173.28.58.2	Perry Engel	Proprietorship	140 2nd Ave NW	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-12	Perry Engel	HRSolutionsContracting@gmail.com	Oelwein	IA	United States	Danette Hager	Tosha Medina	Signed	(1) The employer does not elect the employers’ liability coverage.	Perry Engel	HRSolutionsContracting@gmail.com	Self	Oelwein	IA	United States	Danette Hager	Tosha Medina	Signed
1874	2023-10-22 11:54	Anonymous (not verified)	94.188.205.166	Midwest UAV LLC	Limited Liability Company	1400 15th St SE Bondurant Iowa 50035	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-22	Kaleb Thomas Trammell	kttrammell05@gmail.com	Bondurant	Polk	IA	Alan Willis	Danielle Trammell	Signed	(1) The employer does not elect the employers’ liability coverage.	Kaleb Thomas Trammell	kttrammell05@gmail.com	Owner	Bondurant	Polk	IA	Alan Willis	Danielle Trammell	Signed
33	2020-01-09 15:57	Anonymous (not verified)	173.28.28.57	FALCON PRIDE PROPERTIES LLC	Limited Liability Company	1401 HWY 57 PARKERSBURG, IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-12-13	TODD THOMAS	todd@wimcoach.com	PARKERSBURG	BUTLER	IA	CHAD CAMPBELL	ROXANNE KOLDER	Signed	(1) The employer does not elect the employers’ liability coverage.	TODD THOMAS	todd@wimcoach.com	SELF	PARKERSBURG	BUTLER	IA	CHAD CAMPBELL	ROXANNE KOLDER	Signed
1403	2023-01-03 15:23	Anonymous (not verified)	173.20.50.85	Falcon Pride Properties, LLC	Limited Liability Company	1401 State Highway 57, Parkersburg, IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-23	D. Jay Ellis	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	D. Jay Ellis	cmins_re@mchsi.com	Owner	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
1404	2023-01-03 15:26	Anonymous (not verified)	173.20.50.85	Falcon Pride Properties, LLC	Limited Liability Company	1401 State Highway 57, Parkersburg, IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-23	Todd Thomas	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Todd Thomas	cmins_re@mchsi.com	Owner	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
766	2021-11-22 16:19	Anonymous (not verified)	63.229.189.35	Tribal Tile, LLC	Limited Liability Company	1402 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.	2021-11-22	Josh Loerzel	joshloerzel@gmail.com	Spirit Lake	Dickinson	Iowa	Abigail Miles	Alex Miles	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Loerzel	joshloerzel@gmail.com	Self	SPIRIT LAKE	Dickinson	IA	Abigail Miles	Alex Miles	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
1900	2023-11-09 23:24	Anonymous (not verified)	94.188.207.224	Daniel Blanco	Proprietorship	1403 2nd Ave S	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-09	Daniel Blanco	chindan77@yahoo.com	Fort Dodge	IA	United States	Vanessa Blanco	Jorge Blanco	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Blanco	chindan77@yahoo.com	Self	Fort Dodge	IA	United States	Elva Castañeda	Vanessa Blanco	Signed
641	2021-09-17 09:16	Anonymous (not verified)	72.255.121.118	Osman Gonzalez-Sarceno	Proprietorship	1403 Aspen Dr Adel, 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.	2021-09-17	Osman Gonzalez-Sarceno	workorders@shoproyalflooring.com	Des Moines	Polk	IA	Melissa Bolanos	Brianna Fuller	Signed	(1) The employer does not elect the employers’ liability coverage.	Osman Gonzalez-Sarceno	workorders@shoproyalflooring.com	Owner	Des Moines	Polk	Iowa	Melissa Bolanos	Brianna Fuller	Signed
693	2021-10-26 15:03	Anonymous (not verified)	65.144.174.26	Diamante Tile	Proprietorship	1403 Aspen Dr 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.	2021-10-26	Octavio Bermudez	aerosobo@gmail.com	Des Moines	Dallas	Iowa	Antonia Bermudez	Sofia Piatt	Signed	(1) The employer does not elect the employers’ liability coverage.	Octavio Bermudez	aerosobo@gmail.com	Owner	Adel	Dallas	Iowa	Antonia Bermudez	Sofia Piatt	Signed
1375	2022-11-18 10:21	Anonymous (not verified)	166.181.87.119	Heff Built Construction LLC	Limited Liability Company	1403 Kodiak 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.	2022-11-18	Jacob Heffernen	jheffernen@gmail.com	Cedar Rapids	Linn	IA	Kyle Reid	Amanda Frese	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob Heffernen	jheffernen@gmail.com	N/A	Cedar Rapids	Linn	IA	Kyle Reid	Amanda Frese	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
204	2020-07-15 11:21	Anonymous (not verified)	63.152.54.222	Tim Duggan	Limited Liability Company	1405 1st 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.	2020-07-15	Timothy M Duggan	tdc.inc30@gmail.com	Cedar Rapids	Iowa	United States	Joe Willis	Andrew Anson	Signed	(1) The employer does not elect the employers’ liability coverage.	Timothy M Duggan	tdc.inc30@gmail.com	President	Cedar Rapids	Iowa	United States	Joe Willis	Andrew Anson	Signed
473	2021-04-13 11:26	Anonymous (not verified)	65.103.82.36	Quality Renovation	Proprietorship	1406 25th st 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.	2019-06-21	Clarence Marvin Skipton	marvinthemartien77@gmail.com	Buffalo	Scott	IA	Jennifer Skipton	Rose mary Skipton	Signed	(1) The employer does not elect the employers’ liability coverage.	Clarence Marvin Skipton	marvinthemartien77@gmail.com	Owner	Moline	Rock Island	IL	Jennifer skipton	rose Skipton	Signed
1947	2023-12-07 16:01	Anonymous (not verified)	94.188.205.176	Reinier Construction LLC	Limited Liability Company	1406 Linden 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.	2023-12-07	David J Reinier	reinierconst@aol.com	Des Moines	Polk	IA	PEGGY A ROHDE	Douglas E Rohde	Signed	(1) The employer does not elect the employers’ liability coverage.	PEGGY A ROHDE	dnprohde@msn.com	Bookkeeper	Polk City	Polk	IA	Douglas E Rohde	Stacie L Miller	Signed
668	2021-10-12 16:11	Anonymous (not verified)	173.18.22.217	Mo's Cleaning LLC	Limited Liability Company	1412 E 23rd St Des Moines IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-12	Melissa Jones	commcleanwithme123@gmail.com	Des Moines	Polk	IA	Kelly Coluzzi	Lesa Reeves	Signed	(1) The employer does not elect the employers’ liability coverage.	Melissa Jones	commcleanwithme123@gmail.com	Owner	Des Moines	Polk	IA	Kelly Coluzzi	Lesa Reeves	Signed
1243	2022-08-04 21:00	Anonymous (not verified)	173.24.221.228	Foreman's Tile Creations	Proprietorship	1412 Franklin 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.	2022-08-04	Sole Proprietor	fudog4man@gmail.com	Center Point	Linn	IA	Aaron Foreman	Aaron Foreman	Signed	(1) The employer does not elect the employers’ liability coverage.	Aaron Foreman	fudog4man@gmail.com	I am the Employer	Center Point	Linn	IA	Aaron Foreman	Aaron Foreman	Signed
587	2021-07-26 12:40	Anonymous (not verified)	172.56.7.208	Central Iowa Dict Cleaning	Proprietorship	1414 Adventureland Dr #4206 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.	2021-07-26	Gary Gallagher	ductclean@gmail.com	Altoona	Polk	IA	Meghan Militti	Todd Nastase	Signed	(1) The employer does not elect the employers’ liability coverage.	Gary Gallagher	ductclean@gmail.com	Self	Altoona	Polk	IA	Meghan Militti	Todd Nastase	Signed
1788	2023-08-07 18:32	Anonymous (not verified)	94.188.205.168	Johnson Custom Paint & Design LLC	Limited Liability Company	1414 N 9TH ST	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-07	Josh Johnson	johnsoncustompaint@hotmail.com	Fort Dodge	Iowa	United States	JACKLYN JOHNSON	Roger Johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua Johnson	johnsoncustompaint@hotmail.com	owner	Fort Dodge	IA	United States	JACKLYN JOHNSON	Roger Johnson	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
1341	2022-10-23 14:31	Anonymous (not verified)	97.127.255.147	Traver Home Improvement	Limited Liability Company	14150 110 th Ave. Davenport, IA 52804	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-24	Barry S Traver	traverhomeimprovement@gmail.com	Davenport	IA	United States	Denise Baughman	Joni Bryant	Signed	(1) The employer does not elect the employers’ liability coverage.	Barry S Traver	traverhomeimprovement@gmail.com	self	Davenport	IA	United States	Denise Baughman	Joni Bryant	Signed
1372	2022-11-14 20:36	Anonymous (not verified)	198.14.213.147	Accurate Grading, LLC	Limited Liability Company	1417 290th St Macksburg, IA 50155	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-14	Dustin A McVay	dustin0980@gmail.com	Macksburg	IA	United States	Dustin A McVay	Angela D McVay	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin A McVay	dustin0980@gmail.com	Owner	Macksburg	United States	Iowa	Dustin A McVay	Angela D McVay	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
1663	2023-05-25 12:56	Anonymous (not verified)	94.188.205.167	Affordable Painting and Renovations of Iowa LLC	Limited Liability Company	1417 NW Applewood St. 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.	2023-05-25	Bryan Thieleke	affordablerenoiowa@yahoo.com	Ankeny	Polk	Iowa	Mike kaut	Adam lozano	Signed	(1) The employer does not elect the employers’ liability coverage.	Bryan Thieleke	affordablerenoiowa@yahoo.com	Owner	Ankeny	Polk	Iowa	Mike kaut	Adam lozano	Signed
1662	2023-05-25 12:52	Anonymous (not verified)	94.188.205.176	Affordable Painting and Renovations of Iowa LLC	Limited Liability Company	1418 NW Applewood St. 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.	2023-05-25	Bryan Thieleke	affordablerenoiowa@yahoo.com	Ankeny	Polk	Iowa	Mike Kaut	Adam Lozano	Signed	(1) The employer does not elect the employers’ liability coverage.	Bryan Thieleke	affordablerenoiowa@yahoo.com	Owner	Ankeny	Polk	Iowa	Mike kaut	Adam lozano	Signed
1536	2023-03-27 10:47	Anonymous (not verified)	94.188.205.174	Cecile C Knipp	Limited Liability Company	1418 Oakcrest 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.	2023-03-27	Cecile C Knipp	ceilknipp@gmail.com	Waterloo	Black Hawk	Iowa	Monica Robbins	Anne Betts	Signed	(1) The employer does not elect the employers’ liability coverage.	Cecile C Knipp	christinaknipp@aol.com	Self	Waterloo	Black Hawk	Iowa	Monica Robbins	Anne Betts	Signed
1844	2023-09-14 14:15	Anonymous (not verified)	94.188.205.177	Royal Gutters & Construction, LLC	Limited Liability Company	1420 120th Street, Hazleton, IA 50641	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-01	Andy Hershberger	hershbergera@gmail.com	Hazleton	Buchanan	Iowa	Eli Raber	Steve Frost	Signed	(1) The employer does not elect the employers’ liability coverage.	Andy Herschberger	hershbergera@gmail.com	self	Hazleton	Buchanan	Iowa	Eli Miller	Steve Frost	Signed
1973	2024-01-02 17:05	Anonymous (not verified)	94.188.207.227	Diego Puente	Proprietorship	1420 north st, apt#3 Perry Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-02	Diego Puente Martinez	diegopuente0655@gmail.com	Perry	Dallas	Iowa	Jason Van Dyke	Ashley Heffernen	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Van Dyke	jvandyke@thermalshop.com	worker	Cedar Rapids	Iowa	United States	Jason Van Dyke	Ashley Heffernen	Signed
1871	2023-10-18 10:27	Anonymous (not verified)	94.188.205.169	Derik Gonyier	Proprietorship	1421 Chicago Ave, Savanna, IL 61074	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-14	Derik Ray Gonyier	deriknalexis121413@gmail.com	Savanna	Carroll	IL	Kyle Lee Sturtz	Daryl Gonyier	Signed	(1) The employer does not elect the employers’ liability coverage.	Derik Ray Gonyier	deriknalexis121413@gmail.com	Self	Savanna	Carroll	IL	Kylee Lee	Daryl Eugene Gonyier	Signed
1872	2023-10-18 10:59	Anonymous (not verified)	94.188.205.177	Derik Gonyier	Proprietorship	1421 Chicago Ave, Savanna, IL 61074	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-14	Derik Ray Gonyier	deriknalexis121413@gmail.com	Savanna	Carroll	IL	Kyle Lee Sturtz	Daryl Eugene Gonyier	Signed	(1) The employer does not elect the employers’ liability coverage.	Derik Ray Gonyier	deriknalexis121413@gmail.com	Self	Savanna	Carroll	IL	Kyle Lee Sturtz	Daryl Eugene Gonyier	Signed
1907	2023-11-15 09:45	Anonymous (not verified)	94.188.205.168	Dan Taylor	Proprietorship	1422 State 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.	2023-11-15	Daniel Taylor	mailrunner1958@gmail.com	Mason City	Cerro Gordo	IA	Bob Smith	Dave Clark	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Taylor	mailrunner1958@gmail.com	employee	Mason City	Cerro Gordo	IA	Bob Smith	Dave Clark	Signed
264	2020-09-21 13:26	Anonymous (not verified)	107.77.173.3	JAG Painting	Proprietorship	1423 Des Moines 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.	2020-09-21	Berenice S Silva	berenicesssvaldes@gmail.com	Des Moines	Polk	Iowa	Luis Garcia	Maria Salas	Signed	(1) The employer does not elect the employers’ liability coverage.	Berenice S Silva	berenicesssvaldes@gmail.com	Owner	Des Moines	Polk	Iowa	Luis Garcia	Maria Salas	Signed
349	2020-12-31 17:37	Anonymous (not verified)	107.77.161.33	JAG Painting	Proprietorship	1423 des moines 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.	2020-12-31	Berenice Silva	berenicesssvaldes@gmail.com	Des moines	Polk	IA	Manuel Aguilar	Luis Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Berenice Silva	berenicesssvaldes@gmail.com	Owner	Des moines	Polk	Iowa	Manuel Aguilar	Luis Garcia	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
21	2020-01-01 18:16	Anonymous (not verified)	72.35.186.80	Jerry Arnold	Proprietorship	1426 25th St, Humeston, IA 50123	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Jerry Arnold	LLArnold62@gmail.com	Humeston	Wayne	Iowa	Fred Throckmorton	Joyce Throckmorton	Signed	(1) The employer does not elect the employers’ liability coverage.	Jerry Arnold	LLArnold62@gmail.com	Self	Humeston	Wayne	Iowa	Fred Throckmorton	Joyce Throckmorton	Signed
908	2022-02-09 15:06	Anonymous (not verified)	63.152.66.183	Shear Texture	Limited Liability Company	1427 A Ave NW	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-09	Wendy Kiser	kiser187@msn.com	Cedar Rapids	Linn	Iowa	Shelly Wehr	Kimberly Erickson	Signed	(1) The employer does not elect the employers’ liability coverage.	Wendy Kiser	kiser187@msn.com	Self	Cedar Rapids	Linn	Iowa	Shelly Wehr	Kimberly Erickson	Signed
1586	2023-04-19 08:38	Anonymous (not verified)	94.188.205.169	Arcos Siding, LLC	Limited Liability Company	1429 22nd Street, Des Moines, IA 50311	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-19	Alfredo Arco Cruz	alfredoarcos13@gmail.com	Des Moines	Polk	Des Moines	Maria Sevillana Cruz	Miguel Sevillana	Signed	(1) The employer does not elect the employers’ liability coverage.	Alfredo Arcos Cruz	alfredoarco13@gmail.com	Self	Des Moines	Polk	Iowa	Maria Sevillana Cruz	Miguel Sevillana	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
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
940	2022-03-01 11:08	Anonymous (not verified)	216.51.251.31	trent montgomery trucking llc	Limited Liability Company	1432 eagle ridge circle pierce ne 68767	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-01	trent montgomery	trent.montgomery7@gmail.com	pierce	pierce	nebraska	warren montgomery	travis montgomery	Signed	(1) The employer does not elect the employers’ liability coverage.	trent montgomery	trent.montgomery7@gmail.com	self	pierce	pierce	nebraska	warren douglas montgomery	travis warren montgomery	Signed
182	2020-06-11 14:18	Anonymous (not verified)	173.29.64.73	Diamond Builders of Davenport INC	Proprietorship	14358 275th St, Long grove, IA 52756	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Paula Woods	paulawoods@diamond-builders.com	Long Grove	IA	United States	Colin Woods	Joe Roozeboom	Signed	(1) The employer does not elect the employers’ liability coverage.	Tyler Green	tyler@porterinsuranceinc.com	Insurance Agent	Long Grove	IA	United States	Colin Woods	Joe Roozeboom	Signed
459	2021-04-05 14:24	Anonymous (not verified)	66.188.136.150	Gerald Bosch	Proprietorship	14359 County Rd. G62 Wapello, IA 52653	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-02	Gerald Bosch	kschumacher@tricorinsurance.com	Wapello	Louisa	IA	Russell Masartis	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Gerald Bosch	kschumacher@tricorinsurance.com	Same	Wapello	Louisa	IA	Russell Masartis	Shuree Behr	Signed
1753	2023-07-18 14:41	Anonymous (not verified)	94.188.205.168	Cruz Lerma	Proprietorship	1439 17th Ct 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.	2023-07-18	Cruz Lerma	deb@picowa.com	Des Moines	Polk	Iowa	Deb Stratton	Kelly K Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Cruz Lerma	deb@piciowa.com	self	Des Moines	Polk	Iowa	Deb Stratton	Kelly K Denger	Signed
889	2022-02-03 14:52	Anonymous (not verified)	207.177.96.173	Stecker Rentals Inc.	Limited Liability Company	1439 Kate Shelley Dr. 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.	2022-02-03	Holly Stecker	hollystecker6@gmail.com	Boone	Boone	IA	Shana Mallas	Laura Hutchcroft	Signed	(1) The employer does not elect the employers’ liability coverage.	Holly Stecker	hollystecker6@gmail.com	Owner	Boone	Boone	IA	Shana Mallas	Laura Hutchcroft	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
1510	2023-03-09 10:57	Anonymous (not verified)	94.188.207.226	Sawyer Eblen	Proprietorship	14411 293rd Ave NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-09	Sawyer Eblen	sawyer.eblen@gmail.com	Belgrade	MN	United States	Brandon Keller	Mitchell Vetsch	Signed	(1) The employer does not elect the employers’ liability coverage.	Sawyer Eblen	sawyer.eblen@gmail.com	Owner	Belgrade	MN	United States	Brandon Keller	Mitchell Vetsch	Signed
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
66	2020-02-19 08:48	Anonymous (not verified)	170.232.227.246	CRS Inc	Proprietorship	1442 3rd Ave SW Belmond, IA 50421	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-19	Rebecca Gardner	beckygard1018@gmail.com	Waverly	Bremer	Iowa	Sarah Lowe	Kelsey Poe	Signed	(1) The employer does not elect the employers’ liability coverage.	Rebecca Gardner	beckygard1018@gmail.com	Consultant	Waverly	Bremer	Iowa	Sarah Lowe	Kelsey Poe	Signed
1458	2023-02-16 07:20	Anonymous (not verified)	94.188.205.167	Windsor Earth Works, dba Wells Commercial Flooring	Limited Liability Company	1442 73rd Street, Windsor Heights, Ia. 50324	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-16	Timothy E Wells	wellsba1@msn.com	Windsor Heights	Polk	Iowa	Leonard Klug	Barbara Wells	Signed	(1) The employer does not elect the employers’ liability coverage.	Barbara Wells	wellsba65@gmail.com	Spouse	Windsor Heights	Polk	Iowa	Leonard Klug	Timothy Wells	Signed
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
541	2021-06-15 07:04	Anonymous (not verified)	63.224.181.101	Schultes Horticulture and Landscape LLC	Limited Liability Company	1444 42nd 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.	2021-06-15	Josh Schultes	schulteshort@gmail.com	Des Moines	Iowa	United States	Josh Schultes	Josh Schultes	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Schultes	schulteshort@gmail.com	Self	Des Moines	Iowa	United States	Josh Schultes	Josh Schultes	Signed
1534	2023-03-27 08:16	Anonymous (not verified)	94.188.205.167	Richatd Deist	Proprietorship	1445 Hwy 71 Audubon IA 50025	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-26	Richard Deist	deistfarms@hotmail.com	Audubon	IA	United States	Tara Deist	Pat Groth	Signed	(1) The employer does not elect the employers’ liability coverage.	Bob Miller	bob.miller@millerhybrids.com	seed dealer	Kalona ,Ia	Washington	IA	Tara Deist	Pat Groth	Signed
1535	2023-03-27 09:40	Anonymous (not verified)	94.188.205.167	Richard Deist	Proprietorship	1445 hwy 71 Audubon Ia 50025	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-26	Richard Deist	deistfarms@hotmail.com	Audubon	Audubon	IA	Tara Deist	Pat Groth	Signed	(1) The employer does not elect the employers’ liability coverage.	Bob Miller	bob.miller@millerhybrids.com	Seed dealer	Kalona	Washington	IA	Tara Deist	Pat Groth	Signed
480	2021-04-14 15:58	Anonymous (not verified)	65.103.82.36	Home Cleaning Services	Proprietorship	1448 w 13th St 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.	2020-01-01	Jolene Lyn Brown	j@gmail.com	davenport	scott	IA	Jamie Swanson	Andrew Swanson	Signed	(1) The employer does not elect the employers’ liability coverage.	Jolene Brown	j@gmail.com	owner	davenport	Scott	IA	Jamie Swanson	andrew Swanson	Signed
1483	2023-02-25 14:57	Anonymous (not verified)	94.188.205.168	Van Wyk Lawn Services	Limited Liability Company	14486 S. 128th ave E.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Anthony Eugene Van Wyk	vanwykturf@gmail.com	Lynnville	Iowa	United States	Ashley Lynn Van Wyk	Abby Christine Peterson	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony Eugene Van Wyk	vanwykturf@gmail.com	Self/Owner	Lynnville	Iowa	United States	Ashley Lynn Van Wyk	Abby Christine Peterson	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
2190	2024-04-29 09:28	Anonymous (not verified)	94.188.205.168	JOHNSON OHANA LLC	Limited Liability Company	145 GREENBRIER DR, BURLINGTON, IA 52601	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-29	JARED JOHNSON	KONAOHANAICE@GMAIL.COM	BURINGTON	DES MOINES	IOWA	MARCY KNAUSS	MATTHEW RINKER	Signed	(1) The employer does not elect the employers’ liability coverage.	MAGGIE JOHNSON	KONAOHANAICE@GMAIL.COM	PARTNER/SPOUSE	BURLINGTON	DES MOINES	IOWA	MARCY KNAUSS	MATTHEW RINKER	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
1909	2023-11-15 12:27	Anonymous (not verified)	94.188.207.228	CHAR-LES BUILDINGS LLC	Limited Liability Company	14633 7TH AVE NW, ANDOVER MN 55304	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-15	JOHNNY CHAVEZ CHAVEZ	charlychavez151@gmail.com	ANDOVER	ANOKA	MINNESOTA	ALEIDA LEE	DANY JIMBO	Signed	(1) The employer does not elect the employers’ liability coverage.	JOHNNY CHAVEZ CHAVEZ	charlychavez151@gmail.com	OWNER	ANDOVER	ANOKA	MINNESOTA	ALEIDA LEE	DANY JIMBO	Signed
1334	2022-10-14 08:28	Anonymous (not verified)	67.212.98.135	Verbraken's New Look Painting & Decorating	Proprietorship	147 Barryington 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.	2022-10-14	Donald Verbraken	verbptg@aol.com	Waterloo	Black Hawk	Iowa	Cody Stoppel	Rusty Donnelly	Signed	(1) The employer does not elect the employers’ liability coverage.	Donald Verbraken	verbptg@aol.com	Owner	Waterloo	Black Hawk	Iowa	Cody Stoppel	Rusty Donnelly	Signed
482	2021-04-14 21:21	Anonymous (not verified)	98.17.35.5	K3 Recycling LLC	Limited Liability Company	14801 180th Ave, Milo, IA 50166	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-14	Charles Raymond Kappelman	charliekappelman@yahoo.com	MILO	Warren	United States	Ryan Matthew Kappelman	John Allen Bahr	Signed	(1) The employer does not elect the employers’ liability coverage.	K3 Recycling LLC	charliekappelman@yahoo.com	Co-owner	Milo	Warren	Iowa	Ryan Matthew Kappelman	John Allen Bahr	Signed
755	2021-11-19 13:25	Anonymous (not verified)	65.144.174.26	Central Iowa Insulation and Floors Inc	Proprietorship	14858 118 Ave, 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.	2021-11-19	Ivan Pilat	centraliowaif@gmail.com	Indianola	Warren	Iowa	Mark Kapustin	Vladimir Orbinan	Signed	(1) The employer does not elect the employers’ liability coverage.	Ivan Pilat	centraliowaif@gmail.com	Self	Indianola	Warren	Iowa	Mark Kapustin	Vladimir Orbinan	Signed
2139	2024-04-08 10:35	Anonymous (not verified)	94.188.205.168	Professional Hardwood Floors LLC	Limited Liability Company	14858 118th Ave, 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.	2024-04-08	Ivan Pilat	professionalfloors@ymail.com	Indianola	Warren	iowa	Mark Kapysten	Vladmir Orbedan	Signed	(1) The employer does not elect the employers’ liability coverage.	Ivan Pilat	professionalfloors@ymail.com	Self	Indianola	Warren	Iowa	Mark Kapysten	Vladmir Orbedan	Signed
1387	2022-12-10 22:39	Anonymous (not verified)	98.156.163.144	Springfield Staffing Solution	Limited Liability Company	14918 Tuff Rd, Manor TX 78653	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-10	Beluchukwu Ebede	admin@springfield-staffing.com	Manor	Travis	United States	Oluchukwu Nwokoye	Beluchukwu Ebede	Signed	(1) The employer does not elect the employers’ liability coverage.	Beluchukwu Ebede	admin@springfield-staffing.com	Self	Manor	Travis	United States	Oluchukwu Nwokoye	Beluchukwu Ebede	Signed
1388	2022-12-10 22:42	Anonymous (not verified)	98.156.163.144	Springfield Staffing Solution	Limited Liability Company	14918 Tuff Rd, Manor TX 78653	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-10	Oluchukwu Nwokoye	oly@springfieldstaffing.com	Manor	Travis	United States	Beluchukwu R Ebede	Oluchukwu Nwokoye	Signed	(1) The employer does not elect the employers’ liability coverage.	Beluchukwu Ebede	admin@springfield-staffing.com	Partner	Manor	Travis	United States	Beluchukwu R Ebede	Oluchukwu Nwokoye	Signed
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
986	2022-03-18 16:46	Anonymous (not verified)	174.213.145.90	Gonzalez Contractors LLC.	Limited Liability Company	150 NE 41st St Unit 109	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-18	Elmer Gonzalez	gonzalez922014@icloud.com	Ankeny	Polk	IA	Kassandra Gonzalez	Jesus Gonaalez	Signed	(1) The employer does not elect the employers’ liability coverage.	Elmer Gonzalez	gonzalez922014@icloud.com	Owner	Ankeny	Polk	IA	Kassandra Gonzalez	Jesus Gonzalez	Signed
2006	2024-01-29 11:04	Anonymous (not verified)	94.188.207.224	Kevin Jones	Proprietorship	1500 15Th St. Milford IA 51351	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-29	KEVIN JONES	KEVINMJONES81@GMAIL.COM	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JOSEPH LORING	Signed	(1) The employer does not elect the employers’ liability coverage.	KEVIN JONES	KEVINMJONES81@GMAIL.COM	SELF	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JOSEPH LORING	Signed
2010	2024-01-30 11:46	Anonymous (not verified)	94.188.207.230	Kevin & Jlynn Jones	Proprietorship	1500 15th St. Milford Ia 51351	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-30	Jlynn Jones	KEVINMJONES81@GMAIL.COM	Milford	Dickinson	Iowa	Tami Klein	Joseph Loring	Signed	(1) The employer does not elect the employers’ liability coverage.	Kevin & Jlynn Jones	KEVINMJONES81@GMAIL.COM	Self	Milford	Dickinson	Iowa	Tami Klein	Joseph Loring	Signed
1448	2023-02-10 16:55	Anonymous (not verified)	94.188.205.177	Marks Nursery LLC	Limited Liability Company	15008 310th Trl, Redfield, IA 50233	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-10	Susan L Jones	sljoines026@gmail.com	Redfield	Dallas	Iowa	Douglas Jones	Caitlin Zimmerman	Signed	(1) The employer does not elect the employers’ liability coverage.	Donald Richardson	DonR@phillipsassociatesins.net	Agent	Redfield	Dallas	Iowa	Douglas Zimmerman	Caitlin Zimmerman	Signed
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
824	2022-01-06 20:57	Anonymous (not verified)	209.252.175.92	Rottweiler Remodel & Repair LLC	Limited Liability Company	1503 10th Ave Sw Cedar Rapids Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-06	Zechariah Robert DeLaVergne	rottweilerremodel@gmail.com	Cedar Rapids	Linn County	Iowa	Kathy Maxine Morgan	Daisha Rae Gonzalez	Signed	(1) The employer does not elect the employers’ liability coverage.	Zechariah DeLaVergne	rottweilerremodel@gmail.com	Owner	Cedar Rapids	Linn County	Iowa	Kathy Maxine Morgan	daisha rae gonzalez	Signed
1087	2022-05-04 12:32	Anonymous (not verified)	67.212.117.157	Polk's Lock Service, Inc.	Limited Liability Partnership	1504 College 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.	2022-05-04	Myron Piehl	polkslockservice@gmail.com	Cedar Falls	IA	United States	Jonathon Illian	Katrina Reyerson	Signed	(1) The employer does not elect the employers’ liability coverage.	Myron John Piehl	polkslockservice@gmail.com	owner	Cedar Falls	IA	United States	Jonathan Illian	Katrina Clair Reyerson	Signed
327	2020-11-25 10:38	Anonymous (not verified)	173.31.147.225	CASEY KYLE	Proprietorship	1505 9TH 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.	2020-12-01	CASEY KYLE	JOEL@WALKERINSURANCEIA.COM	MILFORD	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	CASEY KYLE	JOEL@WALKERINSURANCEIA.COM	SELF	MILFORD	DISCKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	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
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
1972	2024-01-02 14:19	Anonymous (not verified)	94.188.205.174	Parker Trucking LLC	Limited Liability Company	1507 Greene Street Adel, IA 50003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-02	Michael Craig Parker	mcparker31@msn.com	Adel	Dallas	Iowa	Jessie Rynearson	Melisha Rynearson	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Parker	mcparker31@msn.com	Owner/Memeber	Adel	Dallas	IA	Jessie Rynearson	Melishia Rynearson	Signed
2067	2024-02-29 16:58	Anonymous (not verified)	94.188.205.166	James Baker	Limited Liability Company	1510 E 1st 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	James Baker	jaykeribaker@yahoo.com	Indianola	Warren	IA	Keri Baker	Brenan Baker	Signed	(1) The employer does not elect the employers’ liability coverage.	James Baker	jaykeribaker@yahoo.com	Self	Indianola	Warren	IA	Keri Baker	Brenan Baker	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
1071	2022-04-26 15:31	Anonymous (not verified)	63.152.69.47	Black squirrel siding llc	Limited Liability Company	1512 n 1st Ave apt c203s coralville,ia52241	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-26	Jeremiah Petsche	jpetsche44@gmail.com	Coralville	Johnson	Iowa	Jessica schimf	Karl schimf	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeremiah petsche	jpetsche44@gmail.com	Myself	Coralville	Johnson	Iowa	Jessica schimf	Karl schimf	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
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
492	2021-04-22 08:33	Anonymous (not verified)	66.188.136.150	Adrian Hackney	Proprietorship	1513 7th 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.	2021-04-20	Adrian Hackney	kschumacher@tricorinsurance.com	Boone	Boone	IA	Shuree Behr	Mitch Kemp	Signed	(1) The employer does not elect the employers’ liability coverage.	Adrian Hackney	kschumacher@tricorinsurance.com	Same	Boone	Boone	IA	Shuree Behr	Mitch Kemp	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
199	2020-07-09 10:49	Anonymous (not verified)	167.142.98.40	Ryan Stott	Proprietorship	1513 Hawthorne 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.	2020-07-09	Ryan Lynn Stott	rlstott@hotmail.com	Jefferson	Greene	Iowa	Brock Chisum	Brian Chisum	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Stott	rlstott@hotmail.com	self	Jefferson	Greene	Iowa	Brock Chisum	Brian Chisum	Signed
1929	2023-11-30 10:46	Anonymous (not verified)	94.188.207.225	White Masonry, Inc.	Proprietorship	15141 Bluff Trl., Carlisle, IA 50047	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-30	Jeff White	whitemasonry1979@hotmail.com	Carlisle	IA	IA	Cathleen Marie White	Sam Jeffrey White	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeffrey Dean White	WHITEMASONRY1979@HOTMAIL.COM	Self	CARLISLE	ia	ia	Cathleen Marie White	Sam Jeffrey White	Signed
1678	2023-06-06 08:13	Anonymous (not verified)	94.188.205.168	Castor Construction	Limited Liability Company	1515 Avenue O Fort Dodge, Iowa 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.	2023-06-06	Kit Hovey	hoveykit@gmail.com	FORT DODGE	Webster	United States	Alexis Malm	Kit Hovey	Signed	(1) The employer does not elect the employers’ liability coverage.	Noah Carspecken	noah@castorconstructionco.com	Management	FORT DODGE	Webster	United States	Alexis Malm	Kit Hovey	Signed
614	2021-08-20 12:20	Anonymous (not verified)	172.58.235.242	Darren Qualls	Proprietorship	1515 Dewitt St. Ellsworth. IA 50075	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-20	Darren Wade Qualls	d.qualls@outlook.com	Ellsworth	Hamilton	IA	Jeannie Kathleen Qualls	Andrea Littleton	Signed	(1) The employer does not elect the employers’ liability coverage.	Darren Wade Qualls	d.qualls@outlook.com	Self/Proprietor	Ellsworth	IA	IA	Jeannie Kathleen Qualls	Andrea Littleton	Signed
1265	2022-08-17 11:10	Anonymous (not verified)	166.181.81.66	Balvanz Electric	Proprietorship	1517 Greenfield 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.	2022-08-17	Brent Balvanz	balvanzelectric@gmail.com	Marshalltown	Iowa	Iowa	Tawnya Dawson	Phyllis Mazour	Signed	(1) The employer does not elect the employers’ liability coverage.	Brent Balvanz	balvanzelectric@gmail.com	Self	Marshalltown	Iowa	Iowa	Tawnya Dawson	Phyllis Mazour	Signed
1266	2022-08-17 11:10	Anonymous (not verified)	166.181.81.66	Balvanz Electric	Proprietorship	1517 Greenfield 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.	2022-08-17	Brent Balvanz	balvanzelectric@gmail.com	Marshalltown	Iowa	Iowa	Tawnya Dawson	Phyllis Mazour	Signed	(1) The employer does not elect the employers’ liability coverage.	Brent Balvanz	balvanzelectric@gmail.com	Self	Marshalltown	Iowa	Iowa	Tawnya Dawson	Phyllis Mazour	Signed
1167	2022-06-23 09:56	Anonymous (not verified)	74.84.106.106	Adam Wamsher	Proprietorship	1517 Ridge Crest Ct Knoxville, IA 50138	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-23	Adam Wamsher	wamshera@hotmail.com	Knoxville	Marion	Iowa	Tina Owens	Kim Owens	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Wamsher	wamshera@hotmail.com	Self	Knoxville	Marion	Iowa	Tina Owens	Kim Owens	Signed
261	2020-09-17 15:52	Anonymous (not verified)	65.127.131.118	Jesus Adrian Martinez	Proprietorship	1517 Searle 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.	2020-09-17	Jesus Adrian Martinez	adrianmartinezventura21@gmail.com	Des Moines	Polk	Iowa	Brian Pruitt	Martin Pinon	Signed	(1) The employer does not elect the employers’ liability coverage.	Jesus Adrian Martinez	adrianmarinezventura21@gmail.com	self	Des Moines	Polk	Iowa	Brian Pruitt	Martin Pinon	Signed
1758	2023-07-20 16:37	Anonymous (not verified)	94.188.205.174	Nailed It Remodeling Services LLC	Limited Liability Company	1520 Burnett Ave 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.	2023-07-20	Kaylyn Christianson	kaylynchristianson@gmail.com	Ames	Story	Iowa	Jon Buller	Terry Miles	Signed	(1) The employer does not elect the employers’ liability coverage.	Kaylyn Christianson	KaylynChristianson@gmail.com	Manager	Ames	Story	Iowa	Jon Buller	Terry Miles	Signed
338	2020-12-13 16:31	Anonymous (not verified)	107.77.161.48	LAVH LLC	Limited Liability Company	1520 E Pleasant View 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.	2020-12-13	Luis Vasquez	vasquezluis239@gmail.com	Des Moines	Polk	Iowa	Lorena Aguilar	Carlos Mendoza	Signed	(1) The employer does not elect the employers’ liability coverage.	LAVH LLC	vasquezluis239@gmail.com	Owner	Des Moines	Polk	Iowa	Lorena Aguilar	Carlos Mendoza	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
1124	2022-05-25 06:32	Anonymous (not verified)	69.77.219.67	J&T Dairy Cattle Company	Proprietorship	1524 290th St. 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.	2022-05-25	Jesse T VanDeStroet	inwoodfeeders@gmail.com	Inwood	Lyon	IA	Josh Tommeraus	Nathan Van Der Wilt	Signed	(1) The employer does not elect the employers’ liability coverage.	Jesse T VanDeStroet	inwoodfeeders@gmail.com	Owner	Inwood	Lyon	Iowa	Josh Tommeraus	Nathan Van Der WIlt	Signed
1125	2022-05-25 06:36	Anonymous (not verified)	69.77.219.67	J&T Dairy Cattle Company	Proprietorship	1524 290th St. 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.	2022-05-25	Tanya Van De Stroet	Accounting@inwoodfeeders.com	Inwood	Lyon	Iowa	Josh Tommeraus	Nathan Van Der Wilt	Signed	(1) The employer does not elect the employers’ liability coverage.	Jesse T VanDeStroet	inwoodfeeders@gmail.com	Owner	Inwood	Lyon	Iowa	Josh Tommeraus	Nathan Van Der Wilt	Signed
1450	2023-02-11 10:59	Anonymous (not verified)	94.188.205.168	JOSE G OLIVAREZ	Limited Liability Company	1529 11TH ST DES MOINES IA 50314	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-11	JOSE G OLIVAREZ	joseolivares742@gmail.com	DES MOINES	POLK	IOWA	SAMIR RAHMANOVIC	SAMIR RAHMANOVIC	Signed	(1) The employer does not elect the employers’ liability coverage.	none	joseolivares742@gmail.com	none	DES MOINES	POLK	IOWA	samir rahmanovic	samir rahmanovic	Signed
1363	2022-11-08 11:37	Anonymous (not verified)	69.76.241.21	S&M Veteran Contracting	Proprietorship	1529 E Ave 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.	2022-11-08	Shane Little	smveterancontracting@gmail.com	Cedar Rapids	Linn County	Iowa	Jordan Nisiewicz	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Regional Recruiter	Kansas City	Clay	MO	Jordan Loyd	Joshua Lafond	Signed
867	2022-01-28 12:19	Anonymous (not verified)	207.199.212.86	Gary Elsbernd DBA RGM Dairy Farm	Proprietorship	1538 230th St Calmar IA, 52132	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-21	Gary Elsbernd	lacy@cioia.com	Calmar	Winneshiek	Iowa	Joel Rochford	Lacy Carolan	Signed	(1) The employer does not elect the employers’ liability coverage.	Gary Elsbernd	lacy@cioia.com	Self	Calmar	Winneshiek	Iowa	Joel Rochford	Lacy Carolan	Signed
868	2022-01-28 12:22	Anonymous (not verified)	207.199.212.86	Gary Elsbernd DBA RGM Dairy Farm	Proprietorship	1538 230th St Calmar IA, 52132	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-21	Marie Elsbernd	lacy@cioia.com	Calmar	Winneshiek	Iowa	Joel Rochford	Lacy Carolan	Signed	(1) The employer does not elect the employers’ liability coverage.	Marie Elsbernd	lacy@cioia.com	Spouse	Calmar	Winneshiek	Iowa	Joel Rochford	Lacy Carolan	Signed
1255	2022-08-15 11:18	Anonymous (not verified)	173.215.77.92	Abby Snyder Design LLC	Limited Liability Company	1540 SE Greenbriar Circle, 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.	2022-08-15	Abby Mae Snyder	abby.mae.snyder@gmail.com	Waukee	Dallas	Iowa	Jenni Wiig	Katy Hildman	Signed	(1) The employer does not elect the employers’ liability coverage.	Abby Mae Snyder	abby.mae.snyder@gmail.com	Self	Waukee	Dallas	Iowa	Jenni Wiig	Katy Hildman	Signed
1271	2022-08-19 08:40	Anonymous (not verified)	75.162.65.221	William Ryerson	Proprietorship	15423 Aurora Ave, 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.	2022-08-19	William Ryerson	churchgirl488@yahoo.com	Urbandale	Dallas	Iowa	Randy Lacina	Laura Lacina	Signed	(1) The employer does not elect the employers’ liability coverage.	William Ryerson	churchgirl488@yahoo.com	Self	Urbandale	Dallas	Iowa	Randy Lacina	Laura Lacina	Signed
637	2021-09-10 15:15	Anonymous (not verified)	204.155.61.217	Duwa Waterproofing LLC	Limited Liability Company	1548 150th 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.	2021-09-10	Stacy Duwa	duwawaterproofing@gmail.com	Mt Pleasant	Henry	Iowa	Jeffrey Spenner	Shawn Powell	Signed	(1) The employer does not elect the employers’ liability coverage.	Stacy Duwa	duwawaterproofing@gmail.com	owner	Mt Pleasant	Henry	Iowa	Jeffrey Spenner	Shawn Powell	Signed
639	2021-09-13 16:10	Anonymous (not verified)	50.81.97.207	Copic Home Maintenance LLC dba Des Moines Drywall Repair	Limited Liability Company	1548 24th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-13	Clint R Copic	crcopic@gmail.com	Des Moines	Polk	Iowa	Veronica G. Torres	Dan Waidelich	Signed	(1) The employer does not elect the employers’ liability coverage.	Clint R Copic	dmdrywallrepair@gmail.com	self	Des Moines	Polk	Iowa	Veronica G Torres	Dan Waidelich	Signed
1410	2023-01-06 10:58	Anonymous (not verified)	173.25.103.95	Bryce Kenworthy	Proprietorship	155 NW Maple St Elkhart IA 50073	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-06	Bryce Kenworthy	midwest.fencingandconstruction@gmail.com	Elkhart	Polk	Iowa	Kevin Corn	Nicole Almburg	Signed	(1) The employer does not elect the employers’ liability coverage.	Bryce Kenworthy	midwest.fencingandconstruction@gmail.com	Owner	Elkhart	Polk	Iowa	Kevin Corn	Nicole Almburg	Signed
1357	2022-11-03 15:06	Anonymous (not verified)	66.129.196.99	Blake Carson	Limited Liability Company	1550 plainview rd ely, IA 52227	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-21	Blake Dennis Carson	Blake@carsondesignsco.com	Ely	Linn	iowa	Dennis Carson	Jordan Mellinger	Signed	(1) The employer does not elect the employers’ liability coverage.	Blake Carson	Blake@carsondesignsco.com	member/Owner	Ely	linn	iowa	Dennis Carson	Jordan Mellinger	Signed
369	2021-01-22 10:02	Anonymous (not verified)	66.188.136.150	Rick Swaney	Proprietorship	1551 Persimmon, Stilwell, OK 74960	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-22	Rick Swaney	kschumacher@tricorinsurance.com	Stilwell	Adair	OK	Russell Masartis	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Swaney	kschumacher@tricorinsurance.com	Same	Stilwell	Adair	OK	Russell Masartis	Shuree Behr	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
1773	2023-08-03 08:24	Anonymous (not verified)	94.188.207.226	LR Construction LLC	Limited Liability Company	1564 110th Street, Hazleton, IA 50641	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-23	Levi R Raber	leviraber@amish.com	Hazleton	Buchanan	Iowa	Mary Ann Reber	Daniel Raber	Signed	(1) The employer does not elect the employers’ liability coverage.	Levi R Raber	leviraber@amish.com	self	Hazleton	Buchanan	Iowa	Julie Schick	Kelly Matt	Signed
1840	2023-09-14 13:48	Anonymous (not verified)	94.188.207.228	L.R. Construction, LLC	Limited Liability Company	1564 110th Street, Hazleton, IA 50641	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-23	Levi R Raber	amish@amish.com	Hazleton	Buchanan	Iowa	Mary Ann Raber	Daniel Raber	Signed	(1) The employer does not elect the employers’ liability coverage.	Levi R Raber	amish@amish.com	self	Hazleton	BUCHANAN	Iowa	Mary Ann Raber	Daniel Raber	Signed
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
556	2021-07-07 09:16	Anonymous (not verified)	66.188.136.150	William Campbell	Proprietorship	159 Friendly Blvd. Springfield, IL 62707	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-06	William Campbell	kschumacher@tricorinsurance.com	Springfield	Sangamon	IL	Mitch Kemp	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	William Campbell	kschumacher@tricorinsurance.com	Same	Springfield	Sangamon	IL	Mitch Kemp	Shuree Behr	Signed
1377	2022-11-21 13:06	Anonymous (not verified)	166.181.84.102	Leaf home solutions	Proprietorship	1595 George Town 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.	2022-11-21	Christopher da von carpenter	chris.carpenter9595@icloud.com	Pleasant hill	Polk	Iowa	Clara Francis carpenter	Thrinadh gutta	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher da von carpenter	chris.carpenter9595@icloud.com	Self	Pleasant hill	Polk	Iowa	Clara Francis carpenter	Thrinadh gutta	Signed
1569	2023-04-12 16:19	Anonymous (not verified)	94.188.205.166	Leaf home solutions llc	Limited Liability Partnership	1595 Georgetown 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.	2023-04-11	Gustavo Lopez	Glopez2616@gmail.com	Des Moines	IA	IA	Ricardo lopez	Maria lopez	Signed	(1) The employer does not elect the employers’ liability coverage.	N/a	sewell@leafhome.com	N/a	Na	Na	Na	Na	Na	Signed
1443	2023-02-07 10:05	Anonymous (not verified)	166.181.84.211	Leaf home solutions	Limited Liability Company	1595 Georgetown rd Hudson Ohio 44236	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-07	Dean Martells	dn.mardesconstruction@gmail.com	Laporte city	Benton	Ia	Jeromia wilson	Todd mcknees	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Yurko	byurko@leacome.com	Recruiter	Hudson	Summit	Ohio	Brian mako	Mat kaulig	Signed
624	2021-08-30 15:53	Anonymous (not verified)	174.253.66.113	Leaf Home Solutions LLC	Limited Liability Company	1595 Georgetown 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.	2021-08-30	Chad York	Cyork027@gmail.com	Davenport	Scott	Iowa	Chad York	Adam Coleman	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Coleman	ARColeman@leafhome.com	Recruiter	Hudson	Summit	Ohio	Chad York	Adam Coleman	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
1924	2023-11-27 12:17	Anonymous (not verified)	94.188.205.166	Leaf Home 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.	2023-11-27	Nathaniel Brundidge	nateotto1313@gmail.com	Osceola	Warren	IA	Barb Dryer	Bob Dryer	Signed	(1) The employer does not elect the employers’ liability coverage.	Monica Acosta	macosta@leafhome.com	Employee	Hudson	Summit	Ohio	Barb Dryer	Bob Dryer	Signed
1436	2023-02-01 11:53	Anonymous (not verified)	174.215.242.112	Leaf home solutions	Limited Liability Company	1595 Georgetown Rd. Hudson, Ohio 44236	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-01	Edward Koch	etkdbq@aol.com	Waterloo	IA	United States	Glenda mclarty	Coen Koch	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian yurko	byurko@leafhome.com	Recruiter	Hudson	Summit	Ohio	Brian Mako	Matt kaulig	Signed
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
1733	2023-07-10 14:30	Anonymous (not verified)	94.188.205.177	Leaf home	Proprietorship	1595 Georgetown Rd., Hudson, OH 44236	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-10	Andrew Koske	aokoz_23@outlook.com	East Moline	IL	United States	Andrew Koske	Andrew Koske	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Koske	aokoz_23@outlook.com	None	East Moline	IL	United States	Andrew Koske	Andrew Koske	Signed
1545	2023-03-29 20:15	Anonymous (not verified)	94.188.205.176	Leaf Filter 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.	2023-03-29	Benjamin Joseph Truitt	Bjt1228@yahoo.com	Springville	Linn	Iowa	Benjamin Joseph Truitt	Jordan Nisiewiczi	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewiczi	jnisiewicz@leafhome.com	Regional field recruiter 2	Riverside	Gallatin	Montana	Benjamin Joseph Truitt	Jordan Nisiewiczi	Signed
817	2021-12-30 12:58	Anonymous (not verified)	50.80.80.37	Leaf Filter	Limited Liability Company	1595 Georgetown Road 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.	2021-12-30	Kenneth Van Hook	kennyvanhook1976@gmail.com	Port Byron	Rock Island	IL	Sharon Van Hook	Judy Hoffman	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody Dunbar	cdunbar@leaffilter.com	Manager	Bettendorf	Scott County	IA	Cody Dunbar	Jordan Nisiewicz	Signed
1993	2024-01-23 07:36	Anonymous (not verified)	94.188.205.168	Leaf Home Solutions LLC	Limited Liability Partnership	1595 Georgetown Road 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.	2024-01-23	Michael Rice	wildblueed@gmail.com	Middle Amana	Iowa	Iowa	Sylvia Rice	Russel Hospadarsky	Signed	(1) The employer does not elect the employers’ liability coverage.	Monica Acosta	macosta@leafhome.com	recruiter	Hudson	Summit	Ohio	Sylvia Rice	Russel Hospadarsky	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
1356	2022-11-02 08:21	Anonymous (not verified)	174.215.249.84	Leaf home solutions	Proprietorship	1595 Georgetown Road, 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.	2022-11-02	Micheal Wills	mwills5304@gmail.com	Granger	Polk	IA	Bryanna Wills	Andrew Vannausdle	Signed	(1) The employer does not elect the employers’ liability coverage.	Bryanna Wills	bryannawills725@gmail.com	None	Granger	Polk	IA	Andrew Vannausdle	Micheal Wills	Signed
628	2021-09-01 09:39	Anonymous (not verified)	204.155.61.217	Utzinger Epoxy & Concrete, LLC	Limited Liability Company	1595 Highway 1 Washington, Iowa 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.	2021-09-01	Troy Utzinger	tbutzinger99@kctc.net	Washington	Washington	Iowa	Jeffrey Spenner	Shawn Powell	Signed	(1) The employer does not elect the employers’ liability coverage.	Troy Utzinger	tbutzinger99@kctc.net	owner	Washington	Washington	Iowa	Jeffrey Spenner	Shawn Powell	Signed
563	2021-07-08 12:16	Anonymous (not verified)	173.17.250.209	Forest Avenue Outreach	Limited Liability Company	1600 6th Ave DSM IA 50314	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-08	Maya Bromolson	maya@goodvibesmovement.org	Des Moines	IA	United States	Joel Donaghy	Brian Donaghy	Signed	(1) The employer does not elect the employers’ liability coverage.	Maya Bromolson	maya@goodvibesmovement.org	Executive Director	Des Moines	IA	United States	Joel Donaghy	Brian Donaghy	Signed
569	2021-07-09 12:18	Anonymous (not verified)	173.17.250.209	Forest Ave Outreach dba Good Vibes Movement	Limited Liability Company	1600 6th Ave DSM IA 50314	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-09	Ben Spellman	ben@goodvibesmovement.org	Des Moines	IA	United States	Joel Donaghy	Brian Donaghy	Signed	(1) The employer does not elect the employers’ liability coverage.	Maya Bromolson	maya@goodvibesmovement.org	Executive Director	Des Moines	IA	United States	Joel Donaghy	Brian Donaghy	Signed
332	2020-12-04 10:57	Anonymous (not verified)	66.188.136.150	Ron's Trucking LLC	Limited Liability Company	16007 Oak Avenue, Oak Forrest, IL 60452	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-12-04	Ronald Clark Jr.	kschumacher@tricorinsurance.com	Oak Forrest	Cook	IL	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron's Trucking LLC	kschumacher@tricorinsurance.com	Same	Oak Forrest	Cook	IL	Russell Masartis	Nancy Wortley	Signed
2150	2024-04-15 12:07	Anonymous (not verified)	94.188.205.177	Todd E Holsteen	Proprietorship	16015 Hwy 99, 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.	2022-11-28	Todd E Holsteen	kellylanz1967@gmail.com	Burlington	IL	United States	David Steele	Kari Holsteen	Signed	(1) The employer does not elect the employers’ liability coverage.	Todd E Holsteen	kellylanz1967@gmail.com	Self	Burlington	IA	United States	David Steele	Kari Holsteen	Signed
2088	2024-03-12 10:44	Anonymous (not verified)	94.188.207.226	Elmer Henry Vicente Lopez	Proprietorship	1602 Court St Apt 2 Sioux City, IA 51105	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-01	Elmer Henry Vicente Lopez	vicenteelmer33@gmail.com	Sioux City	Woodbury	Iowa	Adrian Dominguez	Ronald Halverson	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron Halverson	ron@sppinsurance.com	independent contractor	Cherokee	Cherokee	IA	Elmer Henry Vicente Lopez	Ronald Halverson	Signed
962	2022-03-09 16:45	Anonymous (not verified)	207.199.231.172	Thomas Whitehead	Proprietorship	1602 Green St Oskaloosa, IA 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.	2022-03-09	Thomas Whitehead	roctomjj@mahaska.org	Oskaloosa	Mahaska	Iowa	James Anderson	Ashley Bryan	Signed	(1) The employer does not elect the employers’ liability coverage.	Thomas Whitehead	roctomjj@mahaska.org	Self	Oskaloosa	Mahaska	Iowa	James Anderson	Ashley Bryan	Signed
404	2021-02-16 13:30	Anonymous (not verified)	174.198.79.179	Topline Painting llc	Limited Liability Company	1603 e 32nd st Des Moines IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-16	Michael nunez	toplinepaintingiowa@gmail.com	Des Moines	Polk	Iowa	Jimmy nunez	Jose Nunez	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael nunez	toplinepaintingiowa@gmail.com	Owner	Des moines	Polk	Iowa	Jimmy nunez	Jose nunez	Signed
957	2022-03-08 14:54	Anonymous (not verified)	71.39.227.238	Sharol Williams	Proprietorship	1605 Ash 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.	2022-03-08	Sharol Williams	sharolann48@gmail.com	Dallas Center	Dallas	Iowa	Abbey Luellen	Steve Phillips	Signed	(1) The employer does not elect the employers’ liability coverage.	Sharol Williams	SharolAnn48@gmail.com	Self	Dallas Center	Dallas	Iowa	Abbey Luellen	Steve Phillips	Signed
50	2020-02-03 14:55	Anonymous (not verified)	173.28.28.57	Silverleaf Capital, LLC	Limited Liability Company	1606 Palmer Court, Parkersburg IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-20	Silverleaf Capital, LLC	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Silverleaf Capital, LLC	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
2011	2024-01-31 07:01	Anonymous (not verified)	94.188.205.166	Goede Mechanical	Limited Liability Company	1607 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.	2024-01-31	Don Goede	goedemechanical@gmail.com	Harlan	Shelby	Iowa	Dylan Goede	Kallie Goede	Signed	(1) The employer does not elect the employers’ liability coverage.	Don Goede	goedemechanical@gmail.com	Owner	Harlan	Shelby	Iowa	Dylan Goede	Kallie Goede	Signed
1645	2023-05-12 14:48	Anonymous (not verified)	94.188.207.225	VL Drywall LLC	Limited Liability Company	1608 6th Ave SE Cedar Rapids	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-12	LESLIE LEYVA	lleyva9696@gmail.com	Cedar Rapids	LINN	Iowa	Brad Bower	Chris Hay	Signed	(1) The employer does not elect the employers’ liability coverage.	Leslie Leyva	lleyva9696@gmail.com	Self	Cedar Rapids	Linn	Iowa	Chris Hay	Brad Bower	Signed
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
1839	2023-09-12 11:22	Anonymous (not verified)	94.188.205.167	J.S. Reeves Consulting LLC	Limited Liability Company	1610 1st 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.	2023-09-12	joni Sue Reeves	jonisreeves@att.net	Perry	IA	United States	Maggie Rhodes	Barb Butler	Signed	(1) The employer does not elect the employers’ liability coverage.	Joni Sue Reeves	jsreeves67@gmail.com	Same	Perry	IA	United States	Maggie Rhodes	Barb Butler	Signed
1214	2022-07-20 09:51	Anonymous (not verified)	173.23.180.117	Eric Morse	Proprietorship	1610 Hawthorne Ave, Waterloo, IA 50702	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-09	Eric Richard Morse	ericmorse82@gmail.com	Waterloo	Black Hawk	Iowa	Christine Diane Willis (notary)	Steve Sprague	Signed	(1) The employer does not elect the employers’ liability coverage.	Eric Morse	ericmorse82@gmail.com	Self	Waterloo	Black Hawk	Iowa	Christine Diane Willis (notary)	Steven Sprague	Signed
1820	2023-08-28 08:12	Anonymous (not verified)	94.188.205.177	LLAD Services LLC	Limited Liability Company	1611 Esplanade Avenue Davenport IA 52803	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Austin Lee Terry	austinfarrell92@gmail.com	Davenport	Scott	Iowa	Cody Dunbar	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	JNisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Cody Dunbar	Jordan Loyd	Signed
464	2021-04-07 22:15	Anonymous (not verified)	173.18.251.105	TEMPLEMAN LAWN CARE AND SNOW REMOVAL	Proprietorship	1612 Lomas 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.	2021-04-07	TIM LEE Templeman	nancytempleman@gmail.com	Atlantic	IA	United States	TARA JESSEN	ALFRED WEDE	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	CULLEN AND ASSOCIATES	tammy@cullenins.com	Insurance agent	Atlantic	Cass	Iowa	Tara Jessen	Alfred Wede	Signed
465	2021-04-07 22:24	Anonymous (not verified)	173.18.251.105	TEMPLEMAN LAWN CARE	Proprietorship	1612 Lomas Cr.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-11-01	Tim Lee Templemn	nancytempleman@gmail.com	Atlantic	Iowa	United States	Tara Jessen	Alfred Wede	Signed	(1) The employer does not elect the employers’ liability coverage.	Tim Lee Templeman	nancytempleman@gmail.com	self	Atlantic	Iowa	Iowa	Tara Jessen	Alfred Wede	Signed
265	2020-09-21 14:41	Anonymous (not verified)	74.84.65.174	Nagol Enterprises	Limited Liability Company	16124 PLEASANT VALLEY 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.	2020-09-21	Logan Victor Ante	antelogan@gmail.com	Story CIty	Story	iowa	Brian Wade Warren	Tyler Christian Thompson	Signed	(1) The employer does not elect the employers’ liability coverage.	Logan Victor Ante	antelogan@gmail.com	Same	Story CIty	IA	IA	Brian Wade Warren	Tyler Christian Thompson	Signed
1566	2023-04-12 08:40	Anonymous (not verified)	94.188.205.169	Sabokwigura Jonathan	Proprietorship	1613 12th Avenue Southeast, Cedar Rapids, IA 52401, United States	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-12	Sabokwigura Jonathan	nzobojo@gmail.com	Cedar Rapids	Linn County	Iowa	Jordan Nisiewicz	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Jordan Loyd	Robert Snyder	Signed
1654	2023-05-19 11:09	Anonymous (not verified)	94.188.205.176	ST SULLIVAN CONSTRUCTION COMPANY	Proprietorship	1614 100TH ST., OELWEIN, 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.	2023-05-19	STEVE SULLIVAN	sullycon@msn.com	Oelwein	Fayette	Iowa	Bobbie J Bergan	Shelby Williams	Signed	(1) The employer does not elect the employers’ liability coverage.	STEVE SULLIVAN	sullycon@msn.com	OWNER	OELWEIN	FAYETTE	IOWA	BOBBIE J BERGAN	SHELBY WILLIAMS	Signed
1859	2023-10-04 07:54	Anonymous (not verified)	94.188.205.167	Pacheco Constructrion	Limited Liability Company	1614 Center Street, Des Moines IA 50314	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-04	Ulises Pacheco	info@pachecoconstruction.com	Des Moines	Polk	Iowa	Melissa Gray	Darci Rene Pacheco	Signed	(1) The employer does not elect the employers’ liability coverage.	Ulises Pacheco	info@pachecoconstruction.com	Self	Des Moines	Polk	Iowa	Melissa Gray	Darci Rene Pacheco	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
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
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
1974	2024-01-04 13:12	Anonymous (not verified)	94.188.205.167	Cro Outdoor Services, LLC	Limited Liability Company	1616 NW 78TH 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.	2023-12-20	Bojan Djukic	Croodsia@gmail.com	Clive	Iowa	United States	Cezar Villalobos	Maria Villalobos	Signed	(1) The employer does not elect the employers’ liability coverage.	Evetee Villalobos	e.villalobos91@gmail.com	s/o	Clive	IA	United States	Maria Villalobos	Cezar Villalobos	Signed
1031	2022-04-05 06:47	Anonymous (not verified)	172.58.83.170	Aaron Soboroff	Limited Liability Company	1617 w George Washington Blvd Davenport Iowa 52804	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-05	Aaron P Soboroff	Treedr47@gmail.com	Davenport	Scott	Iowa	Amanda Isenberg	Josh Strother	Signed	(1) The employer does not elect the employers’ liability coverage.	Aaron P Soboroff	Treedr47@gmail.com	Owner Always Mowing	Davenport	Scott	Iowa	Amanda Isenberg	Josh Strother	Signed
876	2022-01-31 11:31	Anonymous (not verified)	75.162.226.236	Leaf Fitters	Limited Liability Company	16180 SE Laurel St Des Moines 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.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-01-31	Rogelio De La Rosa Jr.	chucotx@rocketmail.com	Des Moines	Polk	Iowa	Noreen Henry	Christian Lopez	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Rogelio De La Rosa	chucotx@rocketmail.com	self	Des Moines	polk	ia	noreen henry	Christian Lopez	Signed

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