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:
1775	2023-08-03 09:37	Anonymous (not verified)	94.188.207.227	J j builder llc	Limited Liability Company	2307 richland dr des moines ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-28	José Cruz Jasso balleza	jassoprimo03@icloud.com	Des moines	Polk	Iowa	Jaime Rodrigues	Mario ramos	Signed	(1) The employer does not elect the employers’ liability coverage.	Irving	iibarra@centroinsurance.com	Agent	Des moines	Polk	Iowa	Irving Ibarra	Jaime Rodrigues	Signed
225	2020-08-05 14:31	Anonymous (not verified)	66.188.136.150	William Brickley	Proprietorship	327 E Prairie St., Wataga, IL 61488	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-03	William Brickley	kschumacher@tricorinsurance.com	Watage	Knox	IL	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	William Brickley	kschumacher@tricorinsurance.com	Same	Wataga	Knox	IL	Russell Masartis	Nancy Wortley	Signed
1887	2023-10-31 15:57	Anonymous (not verified)	94.188.207.227	CEM BUSINESSES LLC	Limited Liability Company	608 evergreen cir nw Bondurant, IA 50035	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-31	Dustin Rudolph	dmrudo@gmail.com	Des Moines	Polk	Iowa	Raelynn Aicher	Cameron VanBuren	Signed	(1) The employer does not elect the employers’ liability coverage.	Dane McDonald	dane.mcdonald@stellar-solar.net	Self	Bondurant	Polk	Iowa	Raelynn Aicher	Cameron VanBuren	Signed
337	2020-12-11 21:56	Anonymous (not verified)	66.129.217.166	Tabora Perez Minerva	Proprietorship	4494 Taft Ave SE Trl. 1B 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.	2020-12-01	Tabora Perez Minerva	tonypauljohnson@yahoo.com	Iowa City	Johnson	Iowa	Anthony Johnson	Rafael Donis	Signed	(1) The employer does not elect the employers’ liability coverage.	Tabora Perez Minerva	tonypauljohnson@yahoo.com	Agent	Iowa City	Johnson	IA	Anthony Johnson	Rafael Donis	Signed
1999	2024-01-25 16:57	Anonymous (not verified)	94.188.205.177	Nicholas Schaff	Limited Liability Company	6934 rolling ridge ct sw cedar rapids Iowa 52404	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-25	Nicholas Schaff	schaff.lawncare@gmail.com	cedar rapids	linn	iowa	Brian Zeller	Cassie Schaff	Signed	(1) The employer does not elect the employers’ liability coverage.	Nicholas schaff	schaff.lawncare@gmail.com	Same person	cedar rapids	iowa	iowa	Brian zeller	cassie schaff	Signed
449	2021-03-25 10:53	Anonymous (not verified)	174.198.73.94	A&F Painting llc	Limited Liability Company	411 E Dunham ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-25	Miguel Afanador Olguin	mafanador02@gmail.com	Des Moines	Polk	Iowa	Alfonzo Afanador	Noemi Afanador	Signed	(1) The employer does not elect the employers’ liability coverage.	Miguel Afanador Olguin	mafanador02@gmail.com	Owner	Des Moines	Polk	Iowa	Alfonzo Alfanador	Noemi Alfanador	Signed
2111	2024-03-21 14:28	Anonymous (not verified)	94.188.205.168	James Watson	Limited Liability Company	4708 71st Street Urbandale, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-24	James Edward watson	junior99@email.com	Urbandale	IA	United States	Susie Givant	Doug Frame	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Lantz	jason@lantzelite.com	Employer	Urbandale	IA	United States	Susie Givant	Doug Frame	Signed
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
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
2223	2024-05-14 16:16	Anonymous (not verified)	94.188.205.168	Test	Proprietorship	test	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-14	Test User	aaron.staker@dia.iowa.gov	Test	Test	Test	Test Witness	Test Witness 2	Signed	(1) The employer does not elect the employers’ liability coverage.	Testing	aaron.staker@dia.iowa.gov	Testing	Testing	Testing	Testing	Testing Witness 1	Testing Witness 2	Signed
1024	2022-04-01 09:25	Anonymous (not verified)	173.23.251.188	Norwalk Exterior Home Improvement	Proprietorship	6391 Grimes St 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.	2022-04-01	John Lester	norwalkexterior@gmail.com	Indianola	Warren	Iowa	Tara Murphy	Mike Ryerson	Signed	(1) The employer does not elect the employers’ liability coverage.	John Lester	norwalkexterior@gmail.com	owner	Indianola	Warren	Iowa	Tara Murphy	Mike Ryerson	Signed
673	2021-10-14 07:15	Anonymous (not verified)	97.125.239.203	Complete tile llc	Limited Liability Company	875 se gateway drive #311	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-14	Nedzad mustafic	completetile1@gmail.com	Grimes	Usa	Iowa	Enesa Mustafic	Edina avdic	Signed	(1) The employer does not elect the employers’ liability coverage.	Nedzad Mustafic	completetile1@gmail.com	Owner	Grimes	Usa	Iowa	Enesa mustafic	Edina avdic	Signed
1136	2022-05-31 13:46	Anonymous (not verified)	173.31.148.43	OKOBOJI BURRITO COMPANY LLC	Limited Liability Company	39502 710TH ST LAKEFIELD, MN 56105	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-26	KATHRYN SCHULTZ	kathrynlucier@ymail.com	LAKEFIELD	JACKSON	MN	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	KATHRYN SCHULTZ	kathrynlucier@ymail.com	SELF	LAKEFIELD	JACKSON	MN	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
785	2021-12-09 09:15	Anonymous (not verified)	174.198.75.71	Daniel Vega camacho	Proprietorship	2415 river ,meadows drive Des Moines Iowa 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-09	Daniel Vega camacho	dvega50265@gmail.com	Des Moines	Polk	Iowa	Chad Smith	Adam Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Vega camacho	dvega50265@gmail.com	Self	Des Moines	Polk	Iowa	Chad Smith	Adam Smith	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
1360	2022-11-04 11:13	Anonymous (not verified)	50.81.34.190	Rescue 365 Towing & Salvage	Limited Liability Company	2569 58th St Vinton, IA 52349	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-04	Tyler Schwartz	rescue365@hotmail.com	VAN HORNE	Benton	IA	Tony Harmon	Tracy Beitz	Signed	(1) The employer does not elect the employers’ liability coverage.	Tyler Schwartz	rescue365@hotmail.com	Self	Van Horne	Benton	IA	Tony Harmon	Tracy Beitz	Signed
1472	2023-02-20 15:52	Anonymous (not verified)	94.188.207.230	C & A Fox Farms LLC	Limited Liability Company	3275 Valley Ave Orchard IA 50460	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-20	Curtis Fox	sales@foxfarmsllc.com	Orchard	IOWA	United States	Darrel Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Curtis Fox	sales@foxfarmsllc.com	Self	Orchard	IOWA	United States	Darrel Elsbernd	Chris Fye	Signed
1584	2023-04-18 14:04	Anonymous (not verified)	94.188.205.166	L&J Services LLC	Limited Liability Company	6 highland acres rd marshalltown iowa 50158	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-18	Josh Colwell	centraliowa@fibrenew.com	Marshalltown	IA	United States	Micah Hesse	Hunter Bolinsger	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Colwell	centraliowa@fibrenew.com	Owner	Marshalltown	IA	United States	Micah Hesse	Hunter Bolsinger	Signed
1696	2023-06-19 09:11	Anonymous (not verified)	94.188.205.174	Spruce Cleaning Co	Proprietorship	2302 Cedar Street 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.	2023-06-19	Sarah Champion	Sprucecleaningcodsm@gmail.com	Granger	Dallas	Iowa	Amy Greek	Noah Bassett	Signed	(1) The employer does not elect the employers’ liability coverage.	Sarah Champion	Sprucecleaningcodsm@gmail.com	Employer	Granger	Dallas	Iowa	Amy Greek	Noah Bassett	Signed
17	2019-12-31 09:24	Anonymous (not verified)	72.35.186.80	Grgurich Dozing & Tiling, LLC	Partnership	PO Box 131, Williamson, IA 50272	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Seth Grgurich	mcbroomt15@gmail.com	Williamson	Lucas	Iowa	Eric Curran	Stacy Smyser	Signed	(1) The employer does not elect the employers’ liability coverage.	Seth Grgurich	mcbroomt15@gmail.com	Partner	Williamson	Lucas	Iowa	Eric Curran	Stacy Smyser	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
1791	2023-08-08 15:22	Anonymous (not verified)	94.188.207.227	dutch meadows lawn care	Limited Liability Company	304 W 9TH ST. S.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-08	david nunnikhoven	djnunnik@iowatelecom.net	newton	Iowa	United States	david nunnikhoven	david nunnikhoven	Signed	(1) The employer does not elect the employers’ liability coverage.	david nunnikhoven	djnunnik@iowatelecom.net	owner	newton	Iowa	United States	david nunnikhoven	david nunnikhoven	Signed
241	2020-08-23 16:10	Anonymous (not verified)	67.45.96.12	Wellik & Sons, LLC	Limited Liability Company	1770 HWY 18, Garner, IA 50438	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-23	Jason Yon Juenger	j420money@yahoo.com	Garner	Hancock	Iowa	Joshua P Wellik	Ashley S Wellik	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua Paul Wellik	wellikandsons@gmail.com	subcontractor	Garner	Hancock	Iowa	Joshua Paul Wellik	Ashley S Wellik	Signed
1903	2023-11-13 09:08	Anonymous (not verified)	94.188.207.228	Christopher Stone	Proprietorship	2427 S Taft Ave Apt #8	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-10	Christopher Stone	darrele@ciains.biz	Iowa	Cerro Gordo	IA	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher Stone	darrele@ciains.biz	self	Mason City	Cerro Gordo	Iowa	Chris Fye	Darrel Elsbernd	Signed
353	2021-01-11 14:38	Anonymous (not verified)	66.188.136.150	Igor Curguz	Proprietorship	927 1/2 W Grand Ave.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-11	Igor Curguz	kschumacher@tricorinsurance.com	Beloit	Rock	WI	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	Igor Curguz	kschumacher@tricorinsurance.com	Same	Beloit	Rock	WI	Russell Masartis	Nancy Wortley	Signed
2015	2024-02-01 08:26	Anonymous (not verified)	94.188.207.223	Salazar Builders inc	Proprietorship	29175 365th st van meter ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-01	José Luis ángeles Salazar	salazarbuilders15@gmail.com	Van meter ia	Dallas	Iowa	Adam Paul Boge	Lance Owen Webster	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Luis angeles Salazar	salazarbuilders15@gmail.com	Sub contractor	Van meter	Dallas	Iowa	Adam Paul Boge	Lance Owen Webster	Signed
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
2127	2024-03-29 09:50	Anonymous (not verified)	94.188.205.177	Peterson Home Improvement, LLc	Limited Liability Company	31451 510th Street Russ	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-29	Paul M Peterson	petersonhomeimprovementllc@gmail.com	Russell	Iowa	Iowa	Peggy Jo Peterson	Matthew Peterson	Signed	(1) The employer does not elect the employers’ liability coverage.	Peggy Peterson	petersonhomeimprovementllc@gmail.com	Husband	Russell	Lucas	Iowa	Paul M Peterson	Matthew Peterson	Signed
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
577	2021-07-16 13:45	Anonymous (not verified)	204.155.61.217	Chris & Michele Burke dba Studio Dance	Proprietorship	3907 Center Point Rd NE, Cedar Rapids, IA 52402	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-07-16	Michele Burke	michele@studiodanceia.com	Marion	Linn	Iowa	Molly Feldman	Sharon Naber	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Michele Burke	michele@studiodanceia.com	owner	Marion	Linn	Iowa	Molly Feldman	Sharon Naber	Signed
1040	2022-04-12 09:36	Anonymous (not verified)	173.31.148.43	PAPA'S SMOKIN MEAT	Proprietorship	1940 147TH ST SPIRIT LAKE, IA 51360	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-12	KEITH MORISTON	PAPASSMOKINMEAT@GMAIL.COM	MONTGOMERY	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	KEITH MORISTON	PAPASSMOKINMEAT@GMAIL.COM	SELF	MONTGOMERY	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
689	2021-10-25 14:38	Anonymous (not verified)	107.197.114.249	Brookstin Flooring LLC	Limited Liability Company	1702 Brown Deer Rd Coralville IA 52241	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-10-25	Richard T Klemesrud	rickklemesrud@gmail.com	CORALVILLE	IA	United States	Brian Woods	Sherry Woods	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Richard T Klemesrud	rickklemesrud@gmail.com	Myself / Owner	CORALVILLE	IA	United States	Brian Woods	Sherry Woods	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
801	2021-12-16 21:35	Anonymous (not verified)	98.21.205.195	Kustom Home Improvements	Proprietorship	400 Davidson st new Virginia Iowa 50210	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-16	David Jack Kimmel	kustomhomeimprovements.dk@gmail.com	New Virginia	Warren	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed	(1) The employer does not elect the employers’ liability coverage.	David Jack Kimmel	kustomhomeimprovements.dk@gmail.com	Self	New Virginia	Warren	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed
1264	2022-08-16 21:22	Anonymous (not verified)	50.82.84.19	Nogotta Trucking LLC	Limited Liability Company	16617 Wilden Dr, Clive IA 50325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-16	Adam Dickinson	nogottatruckingllc@gmail.com	Clive	IA	United States	Gary Dickinson	Mike Martens	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Dickinson	nogottatruckingllc@gmail.com	Managing Member	Clive	IA	United States	Gary Dickinson	Mike Martens	Signed
1376	2022-11-18 10:22	Anonymous (not verified)	166.181.87.119	Ashley Heffernen	Proprietorship	4009 Majestic Ct NE Cedar Rapids Iowa 52411	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Ashley Rae Heffernen	ashley.heffernen@gmail.com	Cedar Rapids	Linn	Iowa	Kyle Reid	Amanda Frese	Signed	(1) The employer does not elect the employers’ liability coverage.	Ashley Rae Heffernen	ashley.heffernen@gmail.com	Self	Cedar Rapids	Linn	Iowa	Kyle Reid	Amanda Frese	Signed
1488	2023-02-28 14:04	Anonymous (not verified)	94.188.207.227	Scotts Side Work Plus	Limited Liability Company	304 Wilshire Blvd Windsor Heights IA 50324	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-28	Lansing Scott	scottssideworkplus@gmail.com	Windsor Heights	Iowa	United States	Collin scott	Austyn Scott	Signed	(1) The employer does not elect the employers’ liability coverage.	Lansing Scott	scottssideworkplus@gmail.com	owner	Windsor Heights	Iowa	United States	Austyn Scott	Tracy scott	Signed
1600	2023-04-25 14:38	Anonymous (not verified)	94.188.207.223	martin garcia	Proprietorship	219 austin st sw cedar rapids iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-25	martin garcia ayala	martingarcia2100@gmail.com	cedar rapids	linn	iowa	Ryan Klein	Karina Jacobson	Signed	(1) The employer does not elect the employers’ liability coverage.	martin garcia ayala	martingarcia2100@gmail.com	na	cedar rapids	linn	iowa	Ryan Klein	Karina Jacobson	Signed
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
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
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
1807	2023-08-17 12:45	Anonymous (not verified)	94.188.205.175	LONE STAR ROOFING, LLC	Limited Liability Company	4021 WINDSOR CT DES MOINES, IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-17	RAQUEL B DIAZ MENENDEZ	LONE.STAR.ROOFING76@GMAIL.COM	DES MOINES	USA	IOWA	LILIANA SANCHEZ	RENE ALEXANDER VELASCO	Signed	(1) The employer does not elect the employers’ liability coverage.	LONE STAR ROOFING, LLC	LONE.STAR.ROOFING76@GMAIL.COM	MEMBER OWNER	DES MOINES	USA	IOWA	LILIANA SANCHEZ	RENE ALEXANDER VELASCO	Signed
257	2020-09-14 16:15	Anonymous (not verified)	66.129.217.166	Lisseth Carolina Salas Melendez	Proprietorship	3107 M & W Crl Muscatine, 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.	2020-01-01	Lisseth Carolina Salas Melendez	chonrosales88@gmail.com	Muscatine	Louisa	IA	Rafael Crespo	Anthony Johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	Lisseth Carolina Salas Melendez	chonrosales88@gmail.com	Same	Muscatine	Louisa	IA	Rafael Crespo	Anthony Johnson	Signed
1919	2023-11-21 14:11	Anonymous (not verified)	94.188.207.227	Refined Construction	Limited Liability Company	4148 Mattern ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-21	Dustin Martin	dudtin.martin106@gmail.com	Des Moines	Polk	IA	Kelsey Baldinelli	Brandi Martin	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin Martin	dustin.martin106@gmail.com	Sole officer	Des Moines	Polk	IA	Kelsey Baldinelli	Brandi Martin	Signed
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
2031	2024-02-07 10:54	Anonymous (not verified)	94.188.207.224	PETER MARTENS	Proprietorship	305 4TH STREET NORTH, ALBERT CITY, IOWA 50510	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-07	PETER KLASSEN MARTENS	pkmmartens@hotmail.com	ALBERT CITY	BUENA VISTA	IOWA	ROBERT EUGENE BELT	JOHN CLARENCE OLERICH	Signed	(1) The employer does not elect the employers’ liability coverage.	PETER KLASSEN MARTENS	pkmmartens@hotmail.com	SELF	ALBERT CITY	SAC	IOWA	ROBERT EUGENE BELT	JOHN CLARENCE OLERICH	Signed
481	2021-04-14 17:15	Anonymous (not verified)	199.66.15.81	K3 Recycling	Limited Liability Company	601 W. 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.	2021-04-14	JUSTIN KAPPELMAN	justin@kappelmanappliance.com	Indianola	Iowa	Iowa	Kristy Kappelman	Charlie Kappelman	Signed	(1) The employer does not elect the employers’ liability coverage.	JUSTIN KAPPELMAN	justin@kappelmanappliance.com	Same person	Indianola	IA	IA	Kristy Kappelman	Charlie Kappelman	Signed
2143	2024-04-09 13:05	Anonymous (not verified)	94.188.207.230	CO2 Refrigeration Systems (Iowa) LLC	Limited Liability Company	315 E 5th St Ste 202, Waterloo, IA 50703	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2024-04-09	Zachary Heintz Laws	zach.laws@co2refsystems.com	Marshalltown	Marshall	Iowa	Robert E Shomo	Steven M Madsen	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Zachary Heintz Laws	zach.laws@co2refsystems.com	Self	Marshalltown	Marshall	Iowa	Robert E Shomo	Steven M Madsen	Signed
944	2022-03-03 13:54	Anonymous (not verified)	192.95.125.191	B&R Enterprises LLC	Limited Liability Company	2850 73rd St., Newhall, IA 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.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-02-17	Bradley Rick	ashlyn@3riversins.net	Newhall	Benton	Iowa	Ashlyn Christianson	Angie McFarland	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Ronald Jarrett	brsirenguys@gmail.com	LLC Member	Newhall	Benton	Iowa	Ashlyn Christianson	Angie McFarland	Signed
593	2021-08-03 12:29	Anonymous (not verified)	184.12.14.229	SS Docks LLC	Limited Liability Company	PO Box 561, Okoboji, IA 51355-0561	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-05-21	Jason Snow	k.kooima@q.com	Okoboji	Dickinson	Iowa	Mabel Behnke	Brandi Parks	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jason Snow - SS Docks LLC	k.kooima@q.com	Owner	Okoboji	Dickinson	Iowa	Mabel Behnke	Brandi Parks	Signed

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