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:
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
989	2022-03-21 10:40	Anonymous (not verified)	173.27.156.183	JABS Construction/Finish	Limited Liability Company	543 10th 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.	2022-03-20	Roberto John Henrickson	henricksonroberto10@gmail.com	Clinton	IA	United States	N/A	N/a	Signed	(1) The employer does not elect the employers’ liability coverage.	Roberto John Henrickson	henricksonroberto10@gmail.com	Owner	Clinton	IA	United States	N/A	N/A	Signed
798	2021-12-15 08:03	Anonymous (not verified)	173.22.84.26	LAMPE APPLIANCE SERVICE, Inc	Proprietorship	210 29TH ST 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.	2021-12-15	Jared J Lampe	lampeappliance@gmail.com	CEDAR RAPIDS	Linn	IA	Douglas James Lampe	John Kenneth Lampe	Signed	(1) The employer does not elect the employers’ liability coverage.	Douglas James Lampe	lampeappliance@gmail.com	Vice President	CEDAR RAPIDS	Linn	Iowa	Douglas James Lampe	John Kenneth Lampe	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
1213	2022-07-19 14:00	Anonymous (not verified)	198.14.220.143	VLG Build & Remodle LLC	Limited Liability Partnership	45547 State HWY 14 Chariton, IA 50049	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-19	Vladimir Golosinskiy	VLGCONSTRUCTION@YAHOO.COM	Chariton	IA	United States	Vladimir Golosinskiy	Vladimir Golosinskiy	Signed	(1) The employer does not elect the employers’ liability coverage.	LILIA GOLOSINSKIY	VLGCONSTRUCTION@YAHOO.COM	Wife	CHARITON	Iowa	United States	LILIA GOLOSINSKIY	LILIA GOLOSINSKIY	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
1437	2023-02-01 15:42	Anonymous (not verified)	174.215.242.112	Safe step walk in tub of Minnesota	Limited Liability Company	7300 Washington Ave S. Eden prairie, MN 55344	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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.	James alley	JAlley@safesteptub.com	Vice president of production	Eden prairie	Hennepin	MN	Brent Jarvis	Bruce illies	Signed
1549	2023-03-30 14:22	Anonymous (not verified)	94.188.205.166	BILL MASSENGALE TRUCKING LLC	Limited Liability Company	4583 100TH ST	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-30	WILLIAM MASSENGALE	BLMASSE31@GMAIL.COM	MONTEZUMA	Iowa	United States	Lori Massengale	Brianna Massengale	Signed	(1) The employer does not elect the employers’ liability coverage.	Lori MASSENGALE	BLMASSE31@GMAIL.COM	Spouse	MONTEZUMA	Iowa	United States	WILLIAM MASSENGALE	Brianna MASSENGALE	Signed
1661	2023-05-24 10:12	Anonymous (not verified)	94.188.205.167	Might Lawn Care	Limited Liability Company	1920 W 70th St. Davenport, IA 52806	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-24	Samuel Lawrence Might	mightlawncare@gmail.com	Davenport	Scott	IA	Meredith Might	Suzette Henriksen	Signed	(1) The employer does not elect the employers’ liability coverage.	Samuel Might	mightlawncare@gmail.com	Owner	Davenport	Scott	IA	Meredith Might	Suzette Henriksen	Signed
30	2020-01-07 08:34	Anonymous (not verified)	199.10.5.7	Data Information Management LLC	Limited Liability Company	703 Bluff St Dubuque 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.	2020-01-07	Stephen M Schauff	steve@caricomm.com	Dubuque	Iowa	IA	Janet L Schauff	Morris P Schauff	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher R Broessel	chris@caricomm.com	Partner	Dubuque	Iowa	IA	Janet L Schauff	Morris P schauff	Signed
142	2020-04-28 10:16	Anonymous (not verified)	74.84.101.138	Lutheran Cemetery Association	Proprietorship	410 S. Mechanic Street Decorah, IA 52101	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-18	Timothy A Stoddard	chelsea.whalen@upperiowains.com	Decorah	Winneshiek	IA	Robin C Schultz	Bobbi Jo Berg	Signed	(1) The employer does not elect the employers’ liability coverage.	Timothy A Stoddard	chelsea.whalen@upperiowains.com	Treasurer	Decorah	Winneshiek	IA	Robin C Schultz	Bobbi Jo Berg	Signed
1804	2023-08-16 18:22	Anonymous (not verified)	94.188.207.226	Zach Moyle Masonry	Limited Liability Company	7222 Great River Rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-16	Zach Moyle	zmoylemasonry@gmail.com	Clermont	FAYETTE	FAYETTE	Brittney Loyd	Dave Moyle	Signed	(1) The employer does not elect the employers’ liability coverage.	Zach Moyle	zmoylemasonry@gmail.com	Self	Clermont	FAYETTE	FAYETTE	Brittney Loyd	Dave Moyle	Signed
254	2020-09-10 20:13	Anonymous (not verified)	97.127.219.61	Scott Woodward	Proprietorship	2619 west 69th St. davenport Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-10	Scott Woodward	woodwardscott2001@gmail.com	Davenport	Scott	Iowa	Scott Woodward	Scott Woodward	Signed	(1) The employer does not elect the employers’ liability coverage.	Scott Woodward	woodwardscott2001@gmail.com	Self employed	Davenport	Scott	Iowa	Scott Woodward	Scott Woodward	Signed
1916	2023-11-21 12:31	Anonymous (not verified)	94.188.205.174	DC Painting	Proprietorship	205 Astor St, Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-03	Damion Clement	gcort06@gmail.com	Des Moines	Polk	IA	Brandi Haight	Dennis Clement	Signed	(1) The employer does not elect the employers’ liability coverage.	Damion Clement	gcort06@gmail.com	Owner	205 Astor Street	Polk	IA	Brandi Haight	Dennis Clement	Signed
366	2021-01-18 18:32	Anonymous (not verified)	75.162.57.214	Affordable Exteriors, LLC	Limited Liability Company	802 east COUNTY LINE RD #57	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-18	Destiny Moses	Info@mktdsm.com	DES MOINES	IA	United States	Miguel Angel Garcia Ramirez	Nelly Bekker	Signed	(1) The employer does not elect the employers’ liability coverage.	Destiny Moses	Info@mktdsm.com	owner	DES MOINES	IA	United States	Miguel Garcia	Nellie Bekker	Signed
2028	2024-02-07 09:41	Anonymous (not verified)	94.188.207.228	J & J SIDING	Proprietorship	214 6TH STREET, P.O. BOX 482, LAKE VIEW, IOWA 51450	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-07	JOHN CLARENCE OLERICH	bigo@netins.net	LAKE VIEW	SAC	IOWA	ROBERT EUGENE BELT	NEIL THIESSEN MARTENS	Signed	(1) The employer does not elect the employers’ liability coverage.	JOHN CLARENCE OLERICH	bigo@netins.net	SELF	LAKE VIEW	SAC	IOWA	ROBERT EUGENE BELT	NEIL THIESSEN MARTENS	Signed
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
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
590	2021-07-29 16:38	Anonymous (not verified)	138.43.237.95	Choice Ag Services INC	Proprietorship	1841 Firefly Rd, Manchester, IA 52057	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-29	Joshua Arthur Soppe	choiceagservices@gmail.com	Manchester	Delaware	Iowa	Dustin Fessler	Adam Reth	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua Arthur Soppe	choiceagservices@gmail.com	Owner	Manchester	Delaware	Iowa	Dustin Fessler	Adam Reth	Signed
893	2022-02-03 16:17	Anonymous (not verified)	173.30.138.148	Your Cleaning Solution LLC	Limited Liability Company	P.O. Box 176 Gilbertville IA 50634	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Tricia Olson	toyourcleaningsolution@yahoo.com	Gilbertville	Black Hawk	Ia	Michael Olson	Kathy Heilig	Signed	(1) The employer does not elect the employers’ liability coverage.	Tricia Olson	toyourcleaningsolution@yahoo.com	Same person	Gilbertville	Black Hawk	Ia	Michael Olson	Kathy Heilig	Signed
702	2021-11-01 09:23	Anonymous (not verified)	173.28.195.56	Garcia Snow Removal	Limited Liability Company	213 E 7th Street, West Liberty, Iowa 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.	2021-11-01	Benji A Garcia	garciabenji23@gmail.com	West Liberty	IA	Norway	Luis Ordenana-Choez	Vicente Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Benji Garcia	garciabenji23@gmail.com	Member	West Liberty	Muscatine	Iowa	Luis Ordenana-Choez	Vicente Garcia	Signed
1005	2022-03-24 14:34	Anonymous (not verified)	165.225.57.246	Beardmore Construction	Limited Liability Company	404 E 1st 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.	2022-01-01	Nathan Fosenburg	nfosenburg@yahoo.com	Indianola	Warren	IA	Kerri Fosenburg	Nathan Fosenburg	Signed	(1) The employer does not elect the employers’ liability coverage.	Nathan Fosenburg	nfosenburg@yahoo.com	owner	Indianola	Warren	IA	Kerri Fosenburg	Nathan Fosenburg	Signed
814	2021-12-27 13:07	Anonymous (not verified)	216.51.155.17	I & B Ag Supply, LLC	Limited Liability Company	3807 20th Ave Fenton, IA 50539	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-27	Israel Winter	israel.winter@hotmail.com	Fenton	Kossuth	Iowa	Jonathan Gesink	Benjamin Wiersma	Signed	(1) The employer does not elect the employers’ liability coverage.	Israel Winter	israel.winter@hotmail.com	Member	Fenton	Kossuth	Iowa	Jonathan Gesink	Benjamin Wiersma	Signed
1117	2022-05-18 10:33	Anonymous (not verified)	74.84.106.106	Tina Owens	Proprietorship	4162 Hwy F62 West Monroe, Iowa 50170	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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	Tina M Owens	towens974447@yahoo.com	Monroe	Jasper	Iowa	Ashley Owens	Steve Wimer	Signed	(1) The employer does not elect the employers’ liability coverage.	Tina Owens	towens974447@yahoo.com	self	Monroe	Jasper	Iowa	Ashley Ann Owens	Steve Edwin Wimer	Signed
1229	2022-07-26 15:56	Anonymous (not verified)	173.31.102.238	Rai Neu Jo LLC	Limited Liability Company	957 Westwood Dr NW Cedar Rapids, Iowa 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.	2022-07-26	Craig Edward Johnson	cejohnson119@yahoo.com	Cedar Rapids	Linn	Iowa	Becky Lynn Johnson	Patricia Ann Coghlan	Signed	(1) The employer does not elect the employers’ liability coverage.	Craig Edward Johnson	cejohnson119@yahoo.com	Same person	Cedar Rapids	Linn	Iowa	Becky Lynn Johnson	Patricia Ann Coghlan	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
1453	2023-02-14 07:19	Anonymous (not verified)	94.188.207.230	Milton Gray	Proprietorship	255 10th Ave., Marion, IA 52302, US	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-13	Milton Gray	miltongray23@gmail.com	Marion, IA	Linn	Iowa	Jordan Nisiewicz	Charles Wood	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	MO	Charles Wood	Steven Geisler	Signed
1565	2023-04-11 09:49	Anonymous (not verified)	94.188.205.177	Leonard Moss Roofing	Proprietorship	2018 Superior Street, Webster City, Iowa 50595	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-11	Leonard Moss	leonard.moss48@gmail.com	Webster City	Hamilton	Iowa	Vicky Hahne	Morgan Jensen	Signed	(1) The employer does not elect the employers’ liability coverage.	Leonard Moss	leonard.moss48@gmail.com	Same	Webster City	Hamilton	Iowa	Vicky Hahne	Morgan Jensen	Signed
1677	2023-06-02 11:37	Anonymous (not verified)	94.188.207.230	Karl Klotzbach	Proprietorship	403 Jefferson, Decorah IA 52101	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-02	Karl Klotzbach	kdklotzbach@gmail.com	Decorah	Winneshiek	Iowa	Robin Schultz	Jane Regan	Signed	(1) The employer does not elect the employers’ liability coverage.	Karl Klotzbach	kdklotzbach@gmail.com	Employer	Decorah	Winneshiek	Iowa	Robin Schutlz	Jane M Regan	Signed
46	2020-01-28 16:32	Anonymous (not verified)	173.18.3.76	Delic Marble and Tile LLC	Limited Liability Company	24 Ellefson Dr PO Box 413 DeSoto, IA 50069	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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.	2020-01-27	Lutfija Delic	delicgraniteandtile@gmail.com	Adel	Dallas	Iowa	Angela Kinsey	Taylor Benshoof	Signed	(1) The employer does not elect the employers’ liability coverage.	Adin Delic	delicgraniteandtile@gmail.com	LLC Member	Adel	Dallas	Iowa	Angela Kinsey	Taylor Benshoof	Signed
158	2020-05-18 13:58	Anonymous (not verified)	108.59.100.21	LNM Truck & Trailer Repair LLC	Limited Liability Company	902 Rossville Rd, Waukon, IA 52172	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2020-05-18	Matthew Hawkins	lnmtruckandtrailerrepair@gmail.com	Waterville	Allamakee	IA	Jane M Regan	Chelsea Whalen	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Matthew Hawkins	lnmtruckandtrailerrepair@gmail.com	Owner	Waterville	Allamakee	IA	Jane M Regan	Chelsea Whalen	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
270	2020-09-25 10:14	Anonymous (not verified)	174.243.97.206	J Watts Electric	Limited Liability Company	615 E 2nd 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.	2020-09-25	Jason Watts	jason.watts@jwattselectric.com	Webster City	Hamilton	Iowa	Eli Ochoa	Cody Ewing	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Watts	jason.watts@jwattselectric.com	Self	Webster City	Hamilton	Iowa	Eli Ochoa	Cody Ewing	Signed
1932	2023-12-01 20:02	Anonymous (not verified)	94.188.205.168	Wasabi Johnston LLC	Limited Liability Company	2965 SE Timberline dr, Waukee, IA, 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-01	Enjin zheng	jimmyzheng1573@gmail.com	Waukee	Dallas	Iowa	Jenna Yu	Wen Zheng	Signed	(1) The employer does not elect the employers’ liability coverage.	Enjin zheng	jimmyzheng1573@gmail.com	Owner	Waukee	Dallas	Iowa	Jenna Yu	Wen Zheng	Signed
382	2021-02-02 13:19	Anonymous (not verified)	192.30.185.142	Double D Weatherization	Proprietorship	2069 Glenn Ellen Rd, Sergeant Bluff, IA 51054	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-02	Dale Gernhart	lakehome@longlines.com	Sergeant Bluff	Woodbury	IA	Nate Blaeser	Jenni Ebner	Signed	(1) The employer does not elect the employers’ liability coverage.	Dale Gerhart	lakehome@longlines.com	Self	Sergeant Bluff	Woodbury	IA	Nate Blaeser	Jennie Ebner	Signed
2044	2024-02-15 09:52	Anonymous (not verified)	94.188.205.168	Messenger Trucking LLC	Limited Liability Company	1869 255th 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.	2024-02-08	Timothy Duncan Messenger	tmessengertrucking@gmail.com	Fairfield	Jefferson	Iowa	Casey Messenger	Bud Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Timothy Duncan Messenger	tmessengertrucking@gmail.com	Self	Fairfield	Jefferson	Iowa	Casey Messenger	Bud Smith	Signed
494	2021-04-22 12:41	Anonymous (not verified)	173.18.16.129	Unique Drywall Finishing LLC	Limited Liability Company	509 E 26th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-22	jose angel chavez	uniquewal@yahoo.com	Des Moines	Polk	Iowa	Lesa Reeves	Jen Lambert	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Angel Chavez	uniquewal@yahoo.com	owner	Des Moines	Polk	Iowa	Lesa Reeves	Jen Lambert	Signed
2156	2024-04-16 17:00	Anonymous (not verified)	94.188.205.166	BONILLA STONE LLC	Limited Liability Company	3201 COLUMBIA ST DES MOINES, IA 50313	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-16	JAIRO JAVIER BONILLA SERRANO	jairobonilla509@gmail.com	DES MOINES	POLK	IOWA	ROCIO REYES	JOSE HERNANDEZ	Signed	(1) The employer does not elect the employers’ liability coverage.	JAIRO JAVIER BONILLA SERRANO	jairobonilla509@gmail.com	SAME	DES MOINES	POLK	IOWA	ROCIO REYES	JOSE HERNANDEZ	Signed
606	2021-08-17 12:25	Anonymous (not verified)	69.57.199.231	Precision Painting	Proprietorship	507 Broad St.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-08-17	Daniel Paul Bowser	danshonda12@gmail.com	Reinbeck	Grundy	Iowa	David Paul Bowser	Mary Ellen Sue Bowser	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Sinnott Agency	toms@sinnottagency.com	Insurance provider	Waterloo	Blackhawk	Iowa	David Paul Bowser	Mary Ellen Sue Bowser	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
718	2021-11-05 13:41	Anonymous (not verified)	209.252.172.87	Wayne Hunt	Proprietorship	405 E 4th St Tipton, Ia 52772	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-12	Wayne Hunt	installation@bachmeiercarpetone.com	Tipton	Cedar	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Wayne Hunt	installation@bachmeiercarpetone.com	Self	Tipton	Cedar	Iowa	Sarah Coberley	Heather Howell	Signed
1021	2022-03-30 11:20	Anonymous (not verified)	173.18.22.217	Arti Concrete	Limited Liability Company	6901 SE 14th St Lot #226 Des Moines IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-30	Gerson David Artero	arti.concrete31@gmail.com	Des Moines	Polk	IA	Lesa Reeves	Erick Schuldt	Signed	(1) The employer does not elect the employers’ liability coverage.	Gerson David Artero	arti.concrete31@gmail.com	Owner	Des Moines	Polk	IA	Lesa Reeves	Erick Schuldt	Signed
830	2022-01-11 16:18	Anonymous (not verified)	173.29.117.19	Leaf filter	Proprietorship	866 40th ave Bettendorf, 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.	2022-01-11	Tom Ashby	tashby8@aol.com	Bettendorf	Scott County	IA	Veronica Ashby	Natalie Ashby	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Coleman	arcoleman@leafhome.com	Work coordinator	Bettendorf	Scott	IA	Veronica Ashby	Tom Ashby	Signed
1133	2022-05-29 12:39	Anonymous (not verified)	75.162.116.31	Thompson Trades	Limited Liability Company	3371 200th lane	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-29	shane thompson	shane@thompsontrades.net	prole	IA	IA	Rebecca Thompson	Denyse Thompson	Signed	(1) The employer does not elect the employers’ liability coverage.	shane thompson	shane@thompsontrades.net	owner	prole	IA	IA	Rebecca Ann Thompson	Denyse Rae Thompson	Signed
1245	2022-08-08 09:28	Anonymous (not verified)	174.255.1.240	Jose Rivera	Proprietorship	6100 w lincoln way lot 25 Ames lA 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.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-08-08	Jose Rivera	josechepe91@icloud.com	Ames	Boone	lowa	Jose Rivera	Jose Rivera	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Tim	Tim@thefortress.net	Friends	Ames	Boone	Iowa	Eliazar Martinez	Sabino Díaz	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
1469	2023-02-19 18:23	Anonymous (not verified)	94.188.205.169	Superior Sheet Metal LLC	Limited Liability Company	1819 MM 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.	2023-02-19	Adam Lynn Nielsen	adamnielsen4@yahoo.com	Marengo	Iowa	United States	Emily Jean Nielsen	Joseph Daryl Kriegel	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Lynn Nielsen	adamnielsen4@yahoo.com	Self	Marengo	Iowa	Iowa	Emily Jean Nielsen	Joseph Daryl Kriegel	Signed
171	2020-06-01 16:17	Anonymous (not verified)	99.203.98.130	Jose Jurado	Limited Liability Company	3825 NE 43rd ct Des Moines IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-01	Jose Jurado	trustedroofingllc@gmail.com	Des Moines	Polk	IOWA	Sterling Bean	Sigifredo Corral	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Jurado	trustedroofingllc@gmail.com	Marcos Jurado	Des Moines	Polk	IOWA	Sterling Bean	Sigifredo Corral	Signed
1833	2023-09-08 13:39	Anonymous (not verified)	94.188.207.225	Superior painting & epoxy coatings llc	Limited Liability Company	4918 ne crestmoor ln	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-05	Anthony Negrete jr	superior.paint@hotmail.com	Ankeny	IA	United States	Stacey Marie stoecker	Anthony Negrete jr.	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony Negrete jr	superior.paint@hotmail.com	Spouse	Ankeny	IA	United States	Anthony Negrete jr	stacey marie Stoecker	Signed
283	2020-10-21 09:19	Anonymous (not verified)	192.16.108.199	Blazin Homes	Proprietorship	2306 Hill St Denison Iowa 51442	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-21	Chad David Blasey	chadblasey@yahoo.com	Denison	Crawford	Iowa	Amy Hansen	Todd Stadtlander	Signed	(1) The employer does not elect the employers’ liability coverage.	Chad David Blasey	chadblasey@yahoo.com	Owner	Dension	Crawford	Iowa	Amy Hansen	Todd Stadtlander	Signed

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