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:
763	2021-11-22 12:32	Anonymous (not verified)	63.229.189.35	Adam Dotson Tiling	Proprietorship	324 E 14th Street, Spencer, IA 51301	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-22	Adam Dotson	adamdotson1975@gmail.com	Spencer	Clay	Iowa	Abigail Miles	Alex Miles	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Dotson	adamdotson1975@gmail.com	Self	Spencer	Clay	Iowa	Abigail Miles	Alex Miles	Signed
1738	2023-07-11 10:51	Anonymous (not verified)	94.188.207.224	Augustin Santos	Proprietorship	109 Loomis Ave Des Moines, Iowa 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-05	Augustin Santos	deb@piciowa.com	Des Moines	Polk	Iowa	Deb Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Augustin Santos	deb@piciowa.com	self	Des Moines	Polk	Iowa	Deb Stratton	Kelly Denger	Signed
1913	2023-11-20 13:48	Anonymous (not verified)	94.188.205.167	KWF SALES INC	Proprietorship	216 WINDFLOWER LANE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-20	KRISTI A WOODLEY-FLANSBURG	Kwflansburg@gmail.com	SOLON	Iowa	Iowa	ZACH GRANT	TOM SIMPSON	Signed	(1) The employer does not elect the employers’ liability coverage.	KRISTI A WOODLEY-FLANSBURG	Kwflansburg@gmail.com	SELF	SOLON	IA	IA	ZACH GRANT	TOM SIMPSON	Signed
875	2022-01-31 11:00	Anonymous (not verified)	173.31.102.93	Jhk Construction LLC	Limited Liability Company	6203 Casey 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.	2022-01-31	Edward Charles Loehr	jhkcostruction10@gmail.com	Cedar Rapids	Linn	Iowa	Leanne M Loehr	Autumn G Loehr	Signed	(1) The employer does not elect the employers’ liability coverage.	Jhk Construction LLC	jhkconstruction10@gmail.com	Owner	Cedar Rapids	Linn	Iowa	Leanne M Loehr	Autumn G Loehr	Signed
2025	2024-02-06 20:49	Anonymous (not verified)	94.188.207.223	Blue Dog Stump Grinding	Limited Liability Company	32199 Sumac Road Neola IA 51559	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-06	Zebulan	bluedogstumpgrinding@gmail.com	Neola	Pottowattamie	Iowa	Kelsey Wahle	Mike Stamp	Signed	(1) The employer does not elect the employers’ liability coverage.	Zebulan Wahle	bluedogstumpgrinding@gmail.com	Owner	Neola	Pottowattomie	Iowa	Kelsey Wahle	Mike Stamp	Signed
2137	2024-04-05 10:28	Anonymous (not verified)	94.188.207.227	Innovationsgenc@gmail.com	Limited Liability Company	1134 20th Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-05	Juan carlos Soto Deanda	charlye2512penelope@gmail.com	East Moline	IL	United States	Deja Rivers	Eric Schwab	Signed	(1) The employer does not elect the employers’ liability coverage.	Juan carlos Soto Deanda	charlye2512penelope@gmail.com	Owner	East Moline	IL	United States	Deja Rivers	Eric Schwab	Signed
970	2022-03-14 14:08	Anonymous (not verified)	174.199.79.176	Friends Transportation Services LLC	Limited Liability Company	6010 Creston Ave Unit 26, Des Moines, IA 50321	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-14	Mohammed Dood	mohedali777@hotmail.com	Des Moines	Polk	Iowa	Leigh Laven	Geoff Matlock	Signed	(1) The employer does not elect the employers’ liability coverage.	Mohammed Dood	mohedali777@hotmail.com	Owner	Des Moines	Polk	Iowa	Leigh Laven	Geoff Matlock	Signed
107	2020-03-31 10:47	Anonymous (not verified)	209.152.77.101	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln ST., Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-31	James Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Janice Henningsen	Louise Helmke	Signed	(1) The employer does not elect the employers’ liability coverage.	James Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Janice Henningsen	Louise Helmke	Signed
1082	2022-04-29 12:28	Anonymous (not verified)	75.162.101.109	Jodi Trewet	Proprietorship	11920 NW 114th Ln Granger, IA 50109	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-29	Jodi Trewet	jtrewet@yahoo.com	Granger	IA	United States	Mark Trewet	Tyler Trewet	Signed	(1) The employer does not elect the employers’ liability coverage.	Jodi Trewet	jtrewet@yahoo.com	Same	Granger	Polk	IA	Mark Trewet	Tyler Trewet	Signed
219	2020-07-31 08:49	Anonymous (not verified)	173.31.147.225	JOHN RUPP	Proprietorship	3110 TYLER AVENUE HARTLEY IA 51346	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-30	JOHN P RUPP	THEELECTRICIANLLC@OUTLOOK.COM	HARTLEY	OBRIEN	IOWA	TAMI KLEIN	KRIS WALKER	Signed	(1) The employer does not elect the employers’ liability coverage.	JOHN P RUPP	THEELECTRICIANLLC@OUTLOOK.COM	SELF	HARTLEY	OBRIEN	IA	TAMI KLEIN	KRIS WALKER	Signed
1194	2022-07-08 13:12	Anonymous (not verified)	174.45.15.103	307 Safety LLC	Limited Liability Company	9 Trinidad CT Gillette, WY 82716	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-08	Joshua Peter Tompkins	JTompkins@307Safety.com	Gillette	Campbell	Wyoming	Paul Prather	Jason Praus	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua Peter Tompkins	JTompkins@307Safety.com	Owner	Gillette	Campbell	Wyoming	Paul Prather	Jason Praus	Signed
331	2020-12-03 10:19	Anonymous (not verified)	174.213.165.124	TTC Cleaning Services	Limited Liability Company	2155-230th St Marshalltown, IA. 50158	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-12-03	Zachary Stephen Bolar	zbolar80@gmail.com	Marshalltown	Marshall	IA	Brian Mason	Casey Jesina	Signed	(1) The employer does not elect the employers’ liability coverage.	Zachary Stephen Bolar	zbolar80@gmail.com	Self	Marshall	Marshall	IA	Brian Mason	Casey Jesina	Signed
1306	2022-09-13 15:50	Anonymous (not verified)	96.31.1.206	LUCIO PAINTING	Proprietorship	818 W 4TH ST SPENCER, IA 51301	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-06	LUCIO PENA	joel@walkerinsuranceia.com	SPENCER	CLAY	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	LUCIO PENA	joel@walkerinsuranceia.com	SELF	SPENCER	CLAY	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
443	2021-03-22 13:22	Anonymous (not verified)	167.127.218.244	Romero Carpentry	Proprietorship	2060 King Ave, Apt 19, Des Moines, IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-22	Jose Wilber Romero Batres	Josew.batres@icloud.com	Des moines	Polk	United States	Gabriela Cecibel Chicas	David Antonio Barrera Serrano	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Wilber Romero Batres	Josew.batres@icloud.com	Self	Des Moines	Polk	Iowa	Gabriela Cecibel Chicas	David Antonio Barrera Serrano	Signed
1418	2023-01-11 10:44	Anonymous (not verified)	173.23.144.232	precision edge llc	Limited Liability Company	101 belmont st milo iowa 50116	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-10	erik reha	precisionedgecompanies@gmail.com	milo	warren	iowa	bruce wilson	jordan rhode	Signed	(1) The employer does not elect the employers’ liability coverage.	n/a	precisionedgecompanies@gmail.com	n/a	n/a	n/a	n/a	bruce wilson	jordan rhode	Signed
555	2021-07-06 12:06	Anonymous (not verified)	66.188.136.150	Damond Horner	Proprietorship	44 East Grove Monroe, MI 48162	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-02	Damond Horner	kschumacher@tricorinsurance.com	Monroe	Monroe	MI	Mitch Kemp	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Damond Horner	kschumacher@tricorinsurance.com	Same	Monroe	Monroe	MI	Mitch Kemp	Cody McClain	Signed
1530	2023-03-23 16:14	Anonymous (not verified)	94.188.205.166	Los Cousins gutters	Limited Liability Company	901 sw 62nd st des moines ia 50312	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-23	Freddy Morales	1981ayoria@gmail.com	Des Moines Ia	Polk	Iowa	Denni bazan	Dionicio morales	Signed	(1) The employer does not elect the employers’ liability coverage.	Freddy Morales	1981ayoria@gmail.com	1981ayoria@gmail.com	Desmoines	Polk	Ia	Dennis Bazan	Dionicio Morales	Signed
667	2021-10-11 19:33	Anonymous (not verified)	104.166.240.24	FS Custom Flooring	Limited Liability Company	5729 NW 92nd street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-11	Filip Sakanovic	filip@fscustomflooring.com	Johnston	IA	United States	Senad Sakanovic	Filip Sakanovic	Signed	(1) The employer does not elect the employers’ liability coverage.	FS Tiling and Ceramics	filip@fscustomflooring.com	N/A	Johnston	IA	United States	Senad Sakanovic	Filip Sakanovic	Signed
1642	2023-05-12 07:29	Anonymous (not verified)	94.188.205.169	HARI SWAMI LLC	Limited Liability Company	2759 Mt Pleasant St, Burlington, IA 52601	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-12	BRANDON KELLY	MARKWILLIAMSPRO@GMAIL.COM	FRUIT HEIGHTS	DAVIS	UTAH	MARK WILLIAMS	GREG VANCAMP	Signed	(1) The employer does not elect the employers’ liability coverage.	BRANDON KRLLY	MARKWILLIAMSPRO@GMAIL.COM	SELF	FRUIT HEIGHTS	DAVIS	UTAH	MARK WILLIAMS	GREG VANCAMP	Signed
1817	2023-08-24 12:29	Anonymous (not verified)	94.188.207.223	Global Roofing LLC	Limited Liability Company	504 Heritage Rd Cedar Falls IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-20	Jose Rafael Delgado Marin	grjrd808504@outlook.com	Cedar Falls	Black Hawk	Iowa	Noemi Guerrero	Andres B Montoya	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Rafael Delgado	grjrd808504@outlook.com	member	Cedar Falls	Black Hawk	Iowa	Noemi Guerrero	Andres B Montoya	Signed
779	2021-12-06 10:43	Anonymous (not verified)	172.83.21.144	Munn Enterprises LLC	Limited Liability Company	118 14th Avenue South	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-06	Douglas A Munn	munnent1328@gmail.com	Clear lake	IA	IA	Troy Thomas Munn	Marjorie Marie Munn	Signed	(1) The employer does not elect the employers’ liability coverage.	Troy Munn	Troy@munnentllc.com	Owner	Clear Lake	Cerro Gordo	Iowa	Troy Thomas Munn	Marjorie Marie Munn	Signed
1754	2023-07-19 08:52	Anonymous (not verified)	94.188.207.224	Dustin Scoggins	Limited Liability Company	1723 19th ave rock island Illinois	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-19	Dustin Shane Scoggins	dscoggins625@gmail.com	Rock island	Rock island county	Illinois	Emily Smith-Scoggins	Emily Smith-Scoggins	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin Shane Scoggins	dscoggins625@gmail.com	Self	Rock island	Rock island county	Illinois	Emily Smith-Scoggins	Emily Smith-Scoggins	Signed
1929	2023-11-30 10:46	Anonymous (not verified)	94.188.207.225	White Masonry, Inc.	Proprietorship	15141 Bluff Trl., Carlisle, IA 50047	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-30	Jeff White	whitemasonry1979@hotmail.com	Carlisle	IA	IA	Cathleen Marie White	Sam Jeffrey White	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeffrey Dean White	WHITEMASONRY1979@HOTMAIL.COM	Self	CARLISLE	ia	ia	Cathleen Marie White	Sam Jeffrey White	Signed
2041	2024-02-12 10:37	Anonymous (not verified)	94.188.207.230	Blue Dog Stump Grinding LLC	Limited Liability Company	32199 Sumac Rd Neola, IA 51559	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-12	Zebulan Kent Wahle	bluedogstumpgrinding@gmail.com	Neola	Pottawattamie	Iowa	Kelsey Wahle	Michael Stamp	Signed	(1) The employer does not elect the employers’ liability coverage.	Zebulan Kent Wahle	bluedogstumpgrinding@gmail.com	Self	Neola	Pottawattamie	Iowa	Kelsey Wahle	Michael Stamp	Signed
2153	2024-04-15 21:59	Anonymous (not verified)	94.188.205.167	Ethan M Hoffman	Proprietorship	1442 N. County RD 800, Hamilton, IL 62341	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-07	Ethan M Hoffman	kellylanz1967@gmail.com	Hamilton	IL	United States	Gay Hoffman	Debra Kelley	Signed	(1) The employer does not elect the employers’ liability coverage.	Ethan M Hoffman	kellylanz1967@gmail.com	Self	Hamilton	IL	United States	Gay Hoffman	Debra Kelley	Signed
11	2019-12-17 19:46	Anonymous (not verified)	50.83.188.192	B & B Construction	Proprietorship	2463 93rd Avenue, Norwalk, IA 50211	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-12-17	Louis I. Maxwell	brockbrooke2463@yahoo.com	Norwalk	IA	United States	Hope Winegardner	Yvonne Ginther	Signed	(1) The employer does not elect the employers’ liability coverage.	Louis Maxwell	brockbrooke2463@yahoo.com	Owner	Norwalk	IA	United States	Hope Winegardner	Yvonne Ginther	Signed
986	2022-03-18 16:46	Anonymous (not verified)	174.213.145.90	Gonzalez Contractors LLC.	Limited Liability Company	150 NE 41st St Unit 109	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-18	Elmer Gonzalez	gonzalez922014@icloud.com	Ankeny	Polk	IA	Kassandra Gonzalez	Jesus Gonaalez	Signed	(1) The employer does not elect the employers’ liability coverage.	Elmer Gonzalez	gonzalez922014@icloud.com	Owner	Ankeny	Polk	IA	Kassandra Gonzalez	Jesus Gonzalez	Signed
123	2020-04-16 08:33	Anonymous (not verified)	159.242.36.129	Paul Brown	Proprietorship	5 Cedar Ridge CT, Ventura, IA 50482-8992	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-16	Paul Brown	cedars4@cltel.net	Ventura	Cerro Gordo	IA	Tom Stephany	Amanda Korenberg	Signed	(1) The employer does not elect the employers’ liability coverage.	Paul Brown	cedars4@cltel.net	self	Ventura	Cerro Gordo	IA	Tom Stephany	Amanda Korenberg	Signed
1098	2022-05-12 17:54	Anonymous (not verified)	199.66.15.123	Timothy W Robinson	Proprietorship	302 N Kenwood blvd Indianola IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-12	Timothy William Robinson	williamswork18@gmail.com	Indianola	Warren	Iowa	Sarah Anne Robinson	Andrew Gilbert Barber	Signed	(1) The employer does not elect the employers’ liability coverage.	Timothy William Robinson	williamswork18@gmail.com	Sole proprietor	Indianola	Warren	Iowa	Sarah Anne Robinson	Andrew Gilbert Barber	Signed
235	2020-08-18 13:25	Anonymous (not verified)	50.83.91.36	Tyler Abigt	Proprietorship	636 Crestview Ave Ottumwa, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-18	Tyler Abigt	Abigtlettering@gmail.com	Ottumwa	Wapello	Iowa	Jonathan Strube	Michelle Abigt	Signed	(1) The employer does not elect the employers’ liability coverage.	Tyler Abigt	Abigtlettering@gmail.com	Owner	Ottumwa	Wapello	Iowa	Jonathan Strube	Michelle Abigt	Signed
1210	2022-07-18 08:15	Anonymous (not verified)	173.22.187.234	Cardinal Rule Handyman Services, LLC	Limited Liability Company	1304 E 10th St S, Newton, IA 50208	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-18	James Andrew Dunlap	cardinarulehandyman@gmail.com	Newton	Jasper	Iowa	Jacinda Marie Dunlap	James Thornton Dunlap	Signed	(1) The employer does not elect the employers’ liability coverage.	James Andrew Dunlap	cardinalrulehandyman@gmail.com	I am the authorized agent	Newton	Jasper	Iowa	Jacinda Marie Dunlap	James Thornton Dunlap	Signed
347	2020-12-31 13:44	Anonymous (not verified)	66.129.217.166	Issis Melissa Nunez	Proprietorship	2128 S Riverside Dr. Trl 57, Iowa City, IA 52246	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-12-01	Issis Melissa Nunez	tonypauljohnson@yahoo.com	Iowa City	IA	United States	Anthony Johnson	Olvin Lanza	Signed	(1) The employer does not elect the employers’ liability coverage.	Issis Melissa Nunez	tonypauljohnson@yahoo.com	Owner	Iowa City	IA	United States	Anthony Johnson	Olvin Lanza	Signed
1322	2022-09-27 11:31	Anonymous (not verified)	96.31.4.134	Owens Inspection Services	Limited Liability Company	598 2nd Street SE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-01	Alexander Patrick Owe s	ap_owens_14@yahoo.com	Hospers	Sioux	Iowa	Michael Vander Wilt	Shane Meendering	Signed	(1) The employer does not elect the employers’ liability coverage.	Donald Patrick Owens	dpowens@premieronline.net	Owner	Sioux Center	Sioux	Iowa	Michael Vander Wilt	Shane Meendering	Signed
459	2021-04-05 14:24	Anonymous (not verified)	66.188.136.150	Gerald Bosch	Proprietorship	14359 County Rd. G62 Wapello, IA 52653	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-02	Gerald Bosch	kschumacher@tricorinsurance.com	Wapello	Louisa	IA	Russell Masartis	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Gerald Bosch	kschumacher@tricorinsurance.com	Same	Wapello	Louisa	IA	Russell Masartis	Shuree Behr	Signed
1434	2023-01-31 07:12	Anonymous (not verified)	162.233.75.173	abc	Proprietorship	1122	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-31	Brian Yurko	byurko714@gmail.com	Cedar Falls	Black Hawk	Iowa	pete	re pete	Signed	(1) The employer does not elect the employers’ liability coverage.	LHE	byurko@leafhome.com	contractor	Deerfield Beach	Florida	United States	pete	re pete	Signed
571	2021-07-12 09:51	Anonymous (not verified)	67.55.237.31	Steve Vogel	Proprietorship	314 NE 2ND ST. Panora, Iowa 50216-2020	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-12	Steve Vogel	thevogels@netins.net	PANORA	Guthrie	United States	Diana Vogel	Adam Vogel	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Vogel	thevogels@netins.net	Self	PANORA	Guthrie	Iowa	Diana Vogel	Adam Vogel	Signed
1546	2023-03-29 20:53	Anonymous (not verified)	94.188.205.175	D2 Construction LLC	Limited Liability Company	16192 Wendover Ave Madrid, Iowa 50156	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-29	Dillon Devine	d2construction22@gmail.com	Madrid	Dallas	Iowa	Mark Devine	Jodie Gumm	Signed	(1) The employer does not elect the employers’ liability coverage.	Dillon Devine	d2construction22@gmail.com	Owner	Madrid	Dallas	Iowa	Mark Devine	Jodie Gumm	Signed
683	2021-10-20 09:39	Anonymous (not verified)	173.23.253.122	Superior Floors	Limited Liability Company	704 41st Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-20	Ron Shannon	ronshannon3831@gmail.com	West Des Moines	IA	United States	Virginia Shannon	Virginia Shannon	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron Shannon	ronshannon3831@gmail.com	Self	West Des Moines	IA	United States	Virginia Shannon	Virginia Shannon	Signed
1658	2023-05-23 09:56	Anonymous (not verified)	94.188.205.168	M&D Webster Construction Inc	Proprietorship	1012 Creek Street Webster City IA 50595	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-28	David Gomez	office.seamlesspros@icloud.com	Webster City	Hamilton	Iowa	Jessica Knutson	Keith Clabaugh	Signed	(1) The employer does not elect the employers’ liability coverage.	David Gomez	office.seamlesspros@icloud.com	Self	Webster City	Hamilton	Iowa	Jessica Knutson	Keith Clabaugh	Signed
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
795	2021-12-15 07:47	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	Douglas James Lampe	lampeappliance@gmail.com	CEDAR RAPIDS	IA	IA	John Kenneth Lampe	Kenneth Roman Lampe	Signed	(1) The employer does not elect the employers’ liability coverage.	Douglas James Lampe	lampeappliance@gmail.com	Vice President	Cedar Rapids	Linn	Iowa	John Kenneth Lampe	Kenneth Roman Lampe	Signed
1945	2023-12-06 16:47	Anonymous (not verified)	94.188.205.169	Sell Now Iowa	Limited Liability Company	5525 Meredith Drive Suite B Des Moines Iowa 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-06	Alejandro Bacano Rodriguez	alejandrobacanorodriguez@gmail.com	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Sell Now Iowa	team@sellnowiowa.com	None	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed
2057	2024-02-26 16:17	Anonymous (not verified)	94.188.207.228	Pedro Salazar Trejo	Proprietorship	1116 18th Ave SW Cedar Rapids IA 52402	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-26	Pedro Salazar Trejo	pedrosalazart@icolud.com	Cedar rapids	Linn County	IA	Carlos Izaguirre	Omar Trejo	Signed	(1) The employer does not elect the employers’ liability coverage.	Martiniano Germán Maldonado	maldonadomartiniano675@gmail.com	Employee	Cedar rapids	Linn County	Iowa	Carlos Izaguirre	Omar Trejo	Signed
2169	2024-04-22 09:49	Anonymous (not verified)	94.188.205.166	Galatic Service LLC	Proprietorship	623 1st street silvis IL 61282	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-22	Marcos Gonzales	Marcosg300@yahoo.com	Silvis	Rock Island	IL	Jordan lyod	Jordan Nisiewicz	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas city	Johnson	MO	Marcos Gonzales	Jordan Lyod	Signed
890	2022-02-03 15:11	Anonymous (not verified)	173.23.180.117	E.A. Electric LLC	Limited Liability Company	1065 South Hill Dr, Waterloo, IA 50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-03	Emin Alibegic	emin.alibegic@yahoo.com	Waterloo	Black Hawk	Iowa	Nickole Pry	Christine Willis	Signed	(1) The employer does not elect the employers’ liability coverage.	Emin Alibegic	emin.alibegic@yahoo.com	Same Person	Waterloo	Black Hawk	Iowa	Nickole Pry	Christine Willis	Signed
27	2020-01-06 09:17	Anonymous (not verified)	24.149.10.119	Miss Wonderful LLC	Limited Liability Company	216 Main St Cedar Falls, IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-06	Ann Eastman	misswonderful216@gmail.com	Cedar Falls	Black Hawk	IA	Rachel Lee	Ann Remmert	Signed	(1) The employer does not elect the employers’ liability coverage.	Ann Eastman	misswonderful216@gmail.com	Owner	Cedar Falls	Black Hawk	IA	Rachel Lee	Ann Remmert	Signed
1002	2022-03-23 13:04	Anonymous (not verified)	174.255.6.78	Gonzalez Contractors LLC.	Limited Liability Company	240 NE 41st St unit 203	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-23	Elmer Gonzalez	gonzalez922014@icloud.com	Ankeny	Polk	IA	Kassandra Gonzalez	Jesus Gonzalez	Signed	(1) The employer does not elect the employers’ liability coverage.	Elmer Gonzalez	gonzalez922014@icloud.com	Owner	Ankeny	Polk	IA	Kassandra Gonzalez	Jesus Gonzalez	Signed
139	2020-04-28 10:11	Anonymous (not verified)	74.84.101.138	Nisse Preschool & Kids Place	Partnership	311 College Drive 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.	2020-02-26	Kathleen Schutte	chelsea.whalen@upperiowains.com	Decorah	Winneshiek	IA	Michelle Ostern	Robin C Schultz	Signed	(1) The employer does not elect the employers’ liability coverage.	Kathleen Schutte	chelsea.whalen@upperiowains.com	Treasurer	Decorah	Winneshiek	IA	Michelle Ostern	Robin C Schultz	Signed
1114	2022-05-17 15:30	Anonymous (not verified)	67.212.117.198	Busta Painting	Limited Liability Company	610 W 26th st #1 Cedar Falls, IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-16	Evan Busta	bustapainting@gmail.com	Cedar Falls	IA	United States	Tanner Heikens	Garrett Burrack	Signed	(1) The employer does not elect the employers’ liability coverage.	Evan Busta	bustapainting@gmail.com	Self Employeed	Cedar Falls	IA	United States	Tanner Heikens	Garrett Burrack	Signed
251	2020-09-08 17:00	Anonymous (not verified)	173.27.45.95	Peerless Construction, LLC	Limited Liability Company	4718 E 49th Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-08	Grant Jipp	grant.peerless@gmail.com	Davenport	Scott	Iowa	Dan Knight	Bridget Knight	Signed	(1) The employer does not elect the employers’ liability coverage.	Grant Jipp	grant.peerless@gmail.com	Owner	Davenport	Scott	Iowa	Dan Knight	Bridget Knight	Signed

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