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:
19	2019-12-31 16:29	Anonymous (not verified)	172.58.83.45	A.M. Tile	Proprietorship	3824 122nd 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.	2019-12-31	Amar Music	amarmusic01@gmail.com	Urbandale	IA	United States	Sefik Music	Amara Crncevic	Signed	(1) The employer does not elect the employers’ liability coverage.	Amar Music	amarmusic01@gmail.com	Owner	Urbandale	IA	United States	Sefik Music	Amara Crncevic	Signed
20	2019-12-31 16:36	Anonymous (not verified)	172.58.83.45	A.M. Tile	Proprietorship	3824 122nd 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.	2019-12-31	Amar Music	amarmusic01@gmail.com	Urbandale	IA	United States	Sefik Music	Amara Crncevic	Signed	(1) The employer does not elect the employers’ liability coverage.	Omer Okic	ultimate.exteriors@gmail.com	Owner	Des Moines	Polk	IA	Sefik Music	Amara Crncevic	Signed
21	2020-01-01 18:16	Anonymous (not verified)	72.35.186.80	Jerry Arnold	Proprietorship	1426 25th St, Humeston, IA 50123	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-01	Jerry Arnold	LLArnold62@gmail.com	Humeston	Wayne	Iowa	Fred Throckmorton	Joyce Throckmorton	Signed	(1) The employer does not elect the employers’ liability coverage.	Jerry Arnold	LLArnold62@gmail.com	Self	Humeston	Wayne	Iowa	Fred Throckmorton	Joyce Throckmorton	Signed
22	2020-01-02 14:52	Anonymous (not verified)	173.17.129.166	Dan & Sarah Gudenkauf	Proprietorship	3277 180th Ave, Ryan, IA 52330	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-02	Sarah Gudenkauf	dandselectricmotor@gmail.com	Ryan	Delaware	Iowa	Nicole Almburg	Kevin Corn	Signed	(1) The employer does not elect the employers’ liability coverage.	Sarah Gudenkauf	dandselectricmotor@gmail.com	Owner	Ryan	Delaware	Iowa	Nicole Almburg	Kevin Corn	Signed
23	2020-01-02 14:54	Anonymous (not verified)	173.17.129.166	Dan Gudenkauf	Proprietorship	3277 180th Ave, Ryan, IA 52330	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-02	Dan Gudenkauf	dandselectricmotor@gmail.com	Ryan	Delaware	Iowa	Nicole Almburg	Kevin Corn	Signed	(1) The employer does not elect the employers’ liability coverage.	Dan Gudenkauf	dandselectricmotor@gmail.com	Owner	Ryan	Delaware	Iowa	Nicole Almburg	Kevin Corn	Signed
24	2020-01-03 12:41	Anonymous (not verified)	63.152.13.239	Eden Plumbing LLC TJ Eden	Limited Liability Company	502 Packwaukee Street New Hartford, IA 50660	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-03	TJ Eden	edentj@aol.com	New Hartford	IA	United States	Ann Robinson	Nate Schmidt	Signed	(1) The employer does not elect the employers’ liability coverage.	PDCM Insurance- Nate Schmidt	NSCHMIDT@PDCM.COM	Member	New Hartford	Butler	Iowa	Ann Robinson	Nate Schmidt	Signed
25	2020-01-03 13:09	Anonymous (not verified)	74.84.121.206	Raymond Jones	Proprietorship	P O Box 682 Monona IA 52159	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-11-29	Raymond Jones	darrele@ciains.biz	Monona	Clayton	Iowa	Darrel J Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Darrel J Elsbernd	darrele@ciains.biz	insurance agent	Lime Springs	Howard	Iowa	Darrel J Elsbernd	Chris Fye	Signed
26	2020-01-04 17:23	Anonymous (not verified)	45.53.67.52	Gary De Jager	Limited Liability Company	417 florida Ave NW Orange City Iowa 51041	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-04	Gary Dean De Jager	mightyspear60@yahoo.com	Orange City	Souix	Iowa	Brody Dean De Jager	Tyler Ray De Jager	Signed	(1) The employer does not elect the employers’ liability coverage.	Gary Dean De Jager	mightyspear60@yahoo.com	owner	Orange City	souix	Iowa	Brody Dean De Jager	Tyler Ray De Jager	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
28	2020-01-06 13:39	Anonymous (not verified)	108.178.203.226	MULLIS CATTLE LLC	Limited Liability Company	2506 155TH ST, EARLVILLE IA 52041	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	NICOLAS MULLIS	JAMES@CIOIA.COM	GREELEY	DELAWARE	IOWA	MERRI MOSER	BRITTANY LANSING	Signed	(1) The employer does not elect the employers’ liability coverage.	NICOLAS MULLIS	JAMES@CIOIA.COM	OWNER	GREELEY	DELAWARE	IA	MERRI MOSER	BRITTANY LANSING	Signed
29	2020-01-06 13:44	Anonymous (not verified)	108.178.203.226	MULLIS CATTLE LLC	Limited Liability Company	2506 155TH ST, EARLVILLE IA 52041	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	DAVID MULLIS	JAMES@CIOIA.COM	EARLVILLE	DELAWARE	IOWA	MERRI MOSER	BRITTANY LANSING	Signed	(1) The employer does not elect the employers’ liability coverage.	DAVID MULLIS	JAMES@CIOIA.COM	OWNER	EARLVILLE	DELAWARE	IOWA	MERRI MOSER	BRITTANY LANSING	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
31	2020-01-07 08:37	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	Christopher R Broessel	chris@caricomm.com	Dubuque	Dubuque	IA	Janet L Schauff	Morris P Schauff	Signed	(1) The employer does not elect the employers’ liability coverage.	Stephen M schauff	steve@caricomm.com	Partner	Dubuque IA	Dubuque	Iowa	Janet L schauff	Morris P Schauff	Signed
32	2020-01-08 08:31	Anonymous (not verified)	199.120.118.90	BOBCATS LLC	Limited Liability Company	1860 505TH ST LINN GROVE 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.	2019-11-18	CHRIS AXDAHL	CHRISAXDAHLINC@HOTMAIL.COM	LINN GROVE	CLAY	IOWA	TESSA L STEFFEN	JOSEPH E ZENKOVICH	Signed	(1) The employer does not elect the employers’ liability coverage.	CHRIS AXDAHL	CHRISAXDAHLINC@HOTMAIL.COM	OWNER	LINN GROVE	CLAY	IOWA	TESSA L STEFFEN	JOSEPH E ZENKOVICH	Signed
33	2020-01-09 15:57	Anonymous (not verified)	173.28.28.57	FALCON PRIDE PROPERTIES LLC	Limited Liability Company	1401 HWY 57 PARKERSBURG, IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-12-13	TODD THOMAS	todd@wimcoach.com	PARKERSBURG	BUTLER	IA	CHAD CAMPBELL	ROXANNE KOLDER	Signed	(1) The employer does not elect the employers’ liability coverage.	TODD THOMAS	todd@wimcoach.com	SELF	PARKERSBURG	BUTLER	IA	CHAD CAMPBELL	ROXANNE KOLDER	Signed
34	2020-01-10 15:56	Anonymous (not verified)	74.84.121.206	Milferd Loewen	Proprietorship	6568 Hwy 63, Lime Springs, IA 52155	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-10	Milferd Loewen	darrele@ciains.biz	Lime Springs	Howard	Iowa	Darrel J. Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Milferd Loewen	darrele@ciains.biz	self	Lime Springs	Howard	Iowa	Darrel J. Elsbernd	Chris Fye	Signed
35	2020-01-13 13:23	Anonymous (not verified)	173.28.28.57	Milkhouse Market, LLC	Limited Liability Company	911 Parriott Street, Aplington IA 50604	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-12-30	MARY MEYER	cmins_re@mchsi.com	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	MARY MEYER	cmins_re@mchsi.com	Self	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
36	2020-01-15 13:26	Anonymous (not verified)	173.28.28.57	Shirley Pepples	Proprietorship	206 4th Street, Parkersburg, IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-14	Shirley Pepples	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Shirley Pepples	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
37	2020-01-16 15:26	Anonymous (not verified)	173.24.236.134	Eric Krueger	Proprietorship	406 NE Oak Dr. Ankeny, IA 50021	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-16	Eric Lucas Krueger	erickrugs@gmail.com	Ankeny	Polk	Iowa	Emily Marie Krueger	Roberty William Krueger	Signed	(1) The employer does not elect the employers’ liability coverage.	Eric Krueger	erickrugs@gmail.com	self	Ankeny	Polk	Iowa	Emily Marie Krueger	Robert William Krueger	Signed
38	2020-01-18 12:15	Anonymous (not verified)	206.109.174.199	BJS Frenchies, LLC	Limited Liability Company	20081 Highway J 46 Centerville Iowa 52544	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	J. Jamie Tracy	jamiespuppies@yahoo.com	Centerville	Appanoose	Iowa	Misty O'Hair	Casey Leach	Signed	(1) The employer does not elect the employers’ liability coverage.	Bruce E Tracy	jamiespuppies@yahoo.com	Husband and Co Owner	Centerville	Appanoose	Iowa	Misty O'Hair	Casey Leach	Signed
39	2020-01-19 11:00	Anonymous (not verified)	75.163.84.145	Allen L Bryen	Proprietorship	2609 Madison St Bellevue NE 68005	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-19	Allen Lee Bryen	Allen.Bryen@yahoo.com	Bellevue	Sarpy	Nebraska	Jeffrey Coats	Donald Coats	Signed	(1) The employer does not elect the employers’ liability coverage.	Allen L Bryen	Allen.Bryen@yahoo.com	Self	Bellevue	Sarpy	Nebraska	jeffrey Coats	Donald Coats	Signed
40	2020-01-19 13:20	Anonymous (not verified)	167.142.82.171	Arganbright Land Improvement LLC	Limited Liability Company	2440 Redwood Ave. Guthrie Center, IA 50115	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-19	Josh Arganbright	josh@arganbrightlandimp.com	Guthrie Center	Guthrie	IA	Kim Bauer	Tom Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Arganbright	josh@arganbrightlandimp.com	self	Guthrie Center	Guthrie	IA	Kim Bauer	Tom Smith	Signed
41	2020-01-20 14:26	Anonymous (not verified)	173.24.181.211	BARBARA HOOGEVEEN	Proprietorship	304 MILL POND RD, ROCK RAPIDS, IA 51246	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-20	BARBARA HOOGEVEEN	MCGILLH@MTCNET.NET	ROCK RAPIDS	LYON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	BARABARA HOOGEVEEN	MCGILLH@MTCNET.NET	OWNER	ROCK RAPIDS	LYON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed
42	2020-01-24 12:26	Anonymous (not verified)	173.24.181.211	MIKE EDDY	Proprietorship	PO BOX 437 OKOBOJI, IA 51355	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-22	MIKE EDDY	joel@walkerinsuranceia.com	OKOBOJI	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	MIKE EDDY	JOEL@WALKERINSURANCEIA.COM	OWNER	OKOBOJI	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed
43	2020-01-27 09:23	Anonymous (not verified)	71.199.85.251	ATW Training	Limited Liability Company	4414 114th Street, Urbandale Iowa 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-25	Heather Hampton Cooper	hcooper1@comcast.net	Saint Augustine	Saint Johns	Florida	Terry Lee Cooper	Stacy Thatcher	Signed	(1) The employer does not elect the employers’ liability coverage.	Lynn Roberts	Lynne@atwtraining.com	HR	Des Moines	Polk	Iowa	Cathy Belmont	Mark Purcell	Signed
44	2020-01-28 12:55	Anonymous (not verified)	173.24.181.211	AMANDA FIEDLER	Proprietorship	10 5TH AVE NW FOSTORIA, IA 51340	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-28	AMANDA FIEDLER	JOEL@WALKERINSURANCEIA.COM	FOSTORIA	CLAY	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	AMANDA FIEDLER	JOEL@WALKERINSURANCEIA.COM	OWNER	FOSTORIA	CLAY	IA	JOSPH THOMAS LORING	TAMI SUE KLEIN	Signed
45	2020-01-28 16:13	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.	(1) I am not electing the employers’ liability coverage.	2020-01-31	Adin Delic	delicgraniteandtile@gmail.com	Adel	Dallas	Iowa	Angela Kinsey	Taylor Benshoof	Signed	(1) The employer does not elect the employers’ liability coverage.	Lutfija Delic	delicgraniteandtile@gmail.com	LLC Member	Adel	Dallas	Iowa	Angela Kinsey	Taylor Benshoof	Signed
47	2020-01-28 16:35	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.	(1) I am not electing the employers’ liability coverage.	2020-01-27	Sabahudin 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
48	2020-01-29 13:52	Anonymous (not verified)	97.64.170.98	DARIN J. KESSLER	Proprietorship	1236 25TH ST AMES, IA 50010	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-29	DARIN J. KESSLER	darinjkessler@gmail.com	AMES	STORY	IOWA	HEATHER DIANNE LANNING	JENNY ANN ARENDS	Signed	(1) The employer does not elect the employers’ liability coverage.	DARIN J. KESSLER	darinjkessler@gmail.com	SELF	AMES	STORY	IOWA	HEATHER DIANNE LANNING	JENNY ANN ARENDS	Signed
49	2020-01-31 12:53	Anonymous (not verified)	74.84.121.206	Cody Kleppe	Proprietorship	1891 337th St 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.	2020-01-31	Cody Kleppe	darrele@ciains.biz	Decorah	Winneshiek	Iowa	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Darrel Elsbernd	darrele@ciains.biz	agent	Decorah	Winneshiek	Iowa	Chris Fye	Darrel Elsbernd	Signed
50	2020-02-03 14:55	Anonymous (not verified)	173.28.28.57	Silverleaf Capital, LLC	Limited Liability Company	1606 Palmer Court, Parkersburg IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-20	Silverleaf Capital, LLC	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Silverleaf Capital, LLC	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
51	2020-02-04 10:31	Anonymous (not verified)	173.28.28.57	Sister Style, LLC	Limited Liability Company	211 3rd Street, Parkersburg IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-23	Lisa Ellis	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Lisa Ellis	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
52	2020-02-04 10:35	Anonymous (not verified)	173.28.28.57	Sister Style, LLC	Limited Liability Company	211 3rd Street, Parkersburg IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-23	Amanda Jorgenson	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Amanda Jorgenson	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
53	2020-02-06 11:09	Anonymous (not verified)	65.100.22.228	Bostian Captioning Service, Inc.	Proprietorship	712 8th Avenue 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.	2020-02-06	Dana Bostian	danabostian@msn.com	Oelwein	IA	United States	Lynne Koch	Billie Winters	Signed	(1) The employer does not elect the employers’ liability coverage.	Dana Bostian	danabostian@msn.com	President of Proprietorship	Oelwein	IA	United States	Lynne Koch	Billie Winters	Signed
54	2020-02-06 14:18	Anonymous (not verified)	173.28.28.57	Dale Hansman dba Klinkenborg Hansmann Law Office	Proprietorship	1201 Hwy 57, Parkersburg, IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-14	Dale Hansmann	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Dale Hansmann	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
55	2020-02-07 15:14	Anonymous (not verified)	204.153.176.73	J*M Fuels, LLC	Limited Liability Company	600 W Bremer Avenue, Waverly IA 50677	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-07	Matt Johnson	mattjohnson7555@gmail.com	Jackson TWP	Butler	Iowa	Ty Burke	Lori Frerichs	Signed	(1) The employer does not elect the employers’ liability coverage.	Tylor Burke	tburke@acceladvantage.com	Agent	Waverly	IA	United States	Tony Pollastrini	Lori Frerichs	Signed
56	2020-02-07 15:17	Anonymous (not verified)	204.153.176.73	J*M Fuels, LLC	Limited Liability Company	600 W Bremer Avenue, Waverly IA 50677	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-07	Jim Johnson	mattjohnson7555@gmail.com	Jackson TWP	Butler	Iowa	Ty Burke	Lori Frerichs	Signed	(1) The employer does not elect the employers’ liability coverage.	Ty Burke	tburke@acceladvantage.com	Agent	Waverly	IA	United States	Tony Pollastrini	Lori Frerichs	Signed
57	2020-02-10 15:33	Anonymous (not verified)	198.167.182.164	AllEnhancements LLC	Limited Liability Company	1122 Woodland Ln, LeClaire, IA 52753	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-31	Brett Allen	allenhancementsllc@outlook.com	LeClaire	Scott	Iowa	Steven J Fishman	E Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Brett Allen	allenhancementsllc@outlook.com	Managing Member	LeClaire	Scott	Iowa	Steven J Fishman	E Dyan Kriener	Signed
58	2020-02-10 21:18	Anonymous (not verified)	75.162.11.63	Moni tile Services llc	Limited Liability Company	2207 E Walnut St des Moines iowa 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-01	Monica M Sandoval	Mjsandoval20@yahoo.com	Des Moines	Polk	United States	Cassie Ann bentz	James wesley harkert	Signed	(1) The employer does not elect the employers’ liability coverage.	Moni tile services llc	Mjsandoval20@yahoo.com	Self	Des Moines	Polk	Iowa	Cassie Ann bentz	James wesley harkert	Signed
59	2020-02-11 11:34	Anonymous (not verified)	198.167.182.164	Besch Electric LLC	Limited Liability Company	317 Sycamore St, Riverside, IA 52327	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-03	Daniel Besch	beschd@hotmail.com	Riverside	Washington	Iowa	Steven J Fishman	E Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Besch	beschd@hotmail.com	Managing Member	Riverside	Washington	Iowa	Steven J Fishman	E Dyan Kriener	Signed
60	2020-02-12 10:10	Anonymous (not verified)	198.167.182.164	Sara Torres	Proprietorship	419 Lilac St, Tiffin, IA 52340	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-11	Sara Torres	skb_blue08@hotmail.com	Tiffin	Johnson	Iowa	Steven J Fishman	E. Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Sara Torres	skb_blue08@hotmail.com	Owner	Tiffin	Johnson	Iowa	Steven J Fishman	E Dyan Kriener	Signed
61	2020-02-13 08:44	Anonymous (not verified)	71.28.216.94	Cyclone Captioning, Inc	Proprietorship	8866 W 122nd Street N, Mingo, IA 50168	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-13	Holli L. Schneider	Hlschneid87@gmail.com	Mingo	Jasper	IA	Dan Herrin	Minda Dearden	Signed	(1) The employer does not elect the employers’ liability coverage.	Holli Schneider	hlschneid87@gmail.com	President of Proprietorship	Mingo	Jasper	IA	Dan Herrin	Minda Dearden	Signed
62	2020-02-17 06:55	Anonymous (not verified)	173.31.111.29	Pa's Construction LLC	Limited Liability Company	2350 Glass Rd NE, Cedar Rapids, IA 52402	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-17	Gregory Daniel Saunders	gsaunders.pas@gmail.com	CEDAR RAPIDS	IOWA	United States	Laura Sturm	Chad Johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Saunders	dan2112411@yahoo.com	Owner	Cedar Rapids	Linn	Iowa	Walt Cheney	Mike Broghammer	Signed
63	2020-02-17 16:05	Anonymous (not verified)	173.17.12.213	ANA GARCIA GONZALEZ	Limited Liability Company	4023 14TH ST DES MOINES IOWA 50313	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-17	Ana Garcia Gonzalez	gjeanettegonzalez@gmail.com	DES MOINES	POLK	IOWA	LUZ SAUCEDA	SANDRA ISABEL SAUCEDA	Signed	(1) The employer does not elect the employers’ liability coverage.	ANA GARCIA GONZALEZ	GJEANETTEGONZALEZ@GMAIL.COM	SELF	DES MOINES	POLK	IA	LUZ SOTELO SAUCEDO	SANDRA ISABEL SAUCEDA	Signed
64	2020-02-18 10:02	Anonymous (not verified)	198.167.182.164	Elite Electrical Service LLC	Limited Liability Company	2035 Lynncrest Dr, Coralville, IA 52241	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-18	Sean Brogan	brogan_sean@hotmail.com	Coralville	Johnson	Iowa	Kyle Stahle	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Sean Brogan	brogan_sean@hotmail.com	Managing Member	Coralville	Johnson	Iowa	Kyle Stahle	Dyan Kriener	Signed
65	2020-02-18 15:44	Anonymous (not verified)	70.58.180.91	TD & I CABLE MAINTENANCE INC.	Proprietorship	P.O. BOX 266 LAKELAND MN. 55043	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	FREDERICK W GREEN	FREDGREENCONSTRUCTION@YAHOO.COM	DES MOINES	POLK	IOWA	KATHYRN EILEEN WILLIAMSON	MICHAEL BOYD WILLIAMS	Signed	(1) The employer does not elect the employers’ liability coverage.	LIZZY SHEPARD	LIZZYSHEPARD@TDICABLE.COM	SUBCONTRACTOR	LAKELAND	WASHINGTON	MINNESOTA	KATHRYN EILEEN WILLIAMSON	MICHAEL BOYD WILLIAMS	Signed
66	2020-02-19 08:48	Anonymous (not verified)	170.232.227.246	CRS Inc	Proprietorship	1442 3rd Ave SW Belmond, IA 50421	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-19	Rebecca Gardner	beckygard1018@gmail.com	Waverly	Bremer	Iowa	Sarah Lowe	Kelsey Poe	Signed	(1) The employer does not elect the employers’ liability coverage.	Rebecca Gardner	beckygard1018@gmail.com	Consultant	Waverly	Bremer	Iowa	Sarah Lowe	Kelsey Poe	Signed
67	2020-02-19 10:16	Anonymous (not verified)	198.167.182.164	AWF579 LLC	Limited Liability Company	13 Lynden Dr NE, Iowa City, IA 52240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-18	Jeffrey Schiltz	jeffschiltz2@yahoo.com	Iowa City	Johnson	Iowa	Kyle Stahle	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeffrey Schiltz	jeffschiltz2@yahoo.com	Managing Member	Iowa City	Johnson	Iowa	Kyle Stahle	Dyan Kriener	Signed
68	2020-02-19 12:00	Anonymous (not verified)	198.14.241.59	SIERRA ROOFING LLC	Limited Liability Company	909 N ELM ST WEST LIBERTY IA 52776	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-19	ABRAHAM GRANJENO	SIERRA89@GMAIL.COM	WEST LIBERTY	MUSCATINE	IOWA	JOSE SALGADO	ALEJANDRIA FRAUSTO	Signed	(1) The employer does not elect the employers’ liability coverage.	ABRAHAM GANJENO	SIERRA89@GMAIL.COM	OWNER	WEST LIBERTY	MUSCATINE	IOWA	JOSE SALGADO	ALEJANDRIA FRAUSTO	Signed
69	2020-02-19 15:58	Anonymous (not verified)	198.14.241.59	MORENOS C ROOFING LLC	Limited Liability Company	2018 WATERFRONT DR LOT 73 IOWA CITY IA 52240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-19	RAQUEL OLEA CAMACHO	JORGETREJO19896@GMAIL.COM	IOWA CITY	JOHNSON	IOWA	JORGE TREJO	JOSE SALGADO	Signed	(1) The employer does not elect the employers’ liability coverage.	RAQUEL OLEA CAMACHO	JORGETREJO19896@GMAIL.COM	OWNER	IOWA CITY	JOHNSON	IOWA	JORGE TREJO	JOSE SALGADO	Signed

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