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:
928	2022-02-17 19:46	Anonymous (not verified)	208.83.187.211	Eric Marsh Trucking LLC	Limited Liability Company	1029 Davis Ave Westbrook MN 56183	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-17	Eric Marsh	emt78@yahoo.com	Westbrook	Cottonwood	MN	Dustin Krick	Sam Hansen	Signed	(1) The employer does not elect the employers’ liability coverage.	Eric Marsh	emt78@yahoo.com	Self	Westbrook	Cottonwood	MN	Dustin Krick	Sam Hansen	Signed
1577	2023-04-17 09:58	Anonymous (not verified)	94.188.205.167	Four Leaf LLC	Limited Liability Company	11150 NE 72nd St Bondurant IA 50035	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-17	Eric O'Shea	Fourleaf2021@gmail.com	Bondurant	IA	United States	Lucas Gray	Curt Decker	Signed	(1) The employer does not elect the employers’ liability coverage.	Eric Michael O'Shea	Fourleaf2021@gmail.com	Owner	Bondurant	IA	United States	Lucas Gray	Curt Decker	Signed
1214	2022-07-20 09:51	Anonymous (not verified)	173.23.180.117	Eric Morse	Proprietorship	1610 Hawthorne Ave, Waterloo, IA 50702	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-09	Eric Richard Morse	ericmorse82@gmail.com	Waterloo	Black Hawk	Iowa	Christine Diane Willis (notary)	Steve Sprague	Signed	(1) The employer does not elect the employers’ liability coverage.	Eric Morse	ericmorse82@gmail.com	Self	Waterloo	Black Hawk	Iowa	Christine Diane Willis (notary)	Steven Sprague	Signed
318	2020-11-16 15:06	Anonymous (not verified)	50.82.130.211	Boulder Woodworks, LLC	Limited Liability Company	3011 Boulder Drive, Cedar Falls 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.	2020-10-28	Eric Simmons	cmins_re@mchsi.com	Cedar Falls	Black Hawk	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Eric Simmons	cmins_re@mchsi.com	Self	Cedar Falls	Black Hawk	Iowa	Chad Campbell	Roxanne Kolder	Signed
411	2021-02-22 15:58	Anonymous (not verified)	173.24.190.134	The Willow Tree Garden Center	Limited Liability Company	2103 19rh Street, Emmetsburg IA 50536	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-22	Erica Janssen	mrjanz13@gmail.com	Emmetsburg	Palo Alto	Iowa	Marilee Lace	Candie Clark	Signed	(1) The employer does not elect the employers’ liability coverage.	Erica Janssen	mrjanz13@gmail.com	Member of LLC	Emmetsburg	Palo Alto	Iowa	Marilee Lace	Candie Clark	Signed
2192	2024-04-29 13:15	Anonymous (not verified)	94.188.205.166	ElmStreet Apothecary	Limited Liability Company	320 W Kimberly Road #227	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-29	Erica McGee	esalsbury07@gmail.com	Bettendorf	Scott	Ia	Jennifer West	Julie Francis	Signed	(1) The employer does not elect the employers’ liability coverage.	Erica McGee	esalsbury07@gmail.com	Self	Bettendorf	Scott	Ia	Jennifer West	Julie Francis	Signed
484	2021-04-16 10:58	Anonymous (not verified)	66.188.136.150	Erick Hodges	Proprietorship	3039 Magnolia Dr. Bettendorf, IA 52722	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-16	Erick Hodges	kschumacher@tricorinsurance.com	Bettendorf	Scott	IA	Jordan Bass	Russell Masartis	Signed	(1) The employer does not elect the employers’ liability coverage.	Erick Hodges	kschumacher@tricorinsurance.com	Same	Bettendorf	Scott	IA	Jordan Bass	Russell Masartis	Signed
1708	2023-06-25 15:10	Anonymous (not verified)	94.188.207.228	Lopez concrete	Limited Liability Company	2009 otley ave perry Ia 50220	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-25	Erick Lopez	lopez1concrete@gmail.com	Perry	Dallas	IA	Ever tobar.	Elba alejandro	Signed	(1) The employer does not elect the employers’ liability coverage.	Erick lopez	lopez1concreto@gmail.com	Owner	Perry	Dallas	IA	Ever tobar	Elba alejandro	Signed
834	2022-01-12 17:34	Anonymous (not verified)	67.212.111.166	Cory's Painting LLC	Limited Liability Company	Po Box 1161 Cedar Falls, Iowa 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-13	Erik Bjorn Nelson	ebjornnelson@gmail.com	Waterloo	Black Hawk County	Iowa	Kari Houle	Steven John Swanson	Signed	(1) The employer does not elect the employers’ liability coverage.	Cory Koger	coryspainting@gmail.com	Self	Cedar Falls	Black Hawk County	Iowa	Kari Houle	Steven John Swanson	Signed
400	2021-02-15 14:44	Anonymous (not verified)	192.30.185.142	Certified Radon Mitigation	Proprietorship	4304 Garretson Ave, Sioux City, IA 51106	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-15	Erik Poss	rn222@outlook.com	Sioux City	Woodbury	IA	Katie Jenks	Nate Blaeser	Signed	(1) The employer does not elect the employers’ liability coverage.	Erik Poss	rn222@outlook.com	Owner	Sioux City	Woodbury	IA	Katie Jenks	Nate Blaeser	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
1858	2023-10-03 13:29	Anonymous (not verified)	94.188.207.223	Quad city drywall Solutions LLC	Limited Liability Company	5804 n thornwood ave Davenport iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-03	Erivan Emmanuel Montalvo Delcompare	montalvobills6@gmail.com	Davenport	Scott	Iowa	Natalia Ann Montalvo	Juan Portela	Signed	(1) The employer does not elect the employers’ liability coverage.	Erivan Emmanuel Montalvo Delcompare	montalvobills6@gmail.com	Owner	Davenport	Scott	Iowa	Natalia Montalvo	Juan Portela	Signed
2046	2024-02-15 11:29	Anonymous (not verified)	94.188.205.175	Ervin Cabrera Mendez	Proprietorship	4822 Meadowlark Lane, Sioux City, Iowa 51106	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-01	Ervin Cabrera Mendez	ervincabrera89@gmail.com	Sioux City	Woodbury	Iowa	Kyle Buum	David Jacobs	Signed	(1) The employer does not elect the employers’ liability coverage.	Ervin Cabrera Mendez	ervincabrera89@gmail.com	Owner	Sioux City	Woodbury	Iowa	Kyle Buum	David Jacobs	Signed
1769	2023-07-31 11:23	Anonymous (not verified)	94.188.207.228	PSI LLC	Limited Liability Company	2765 N Center Point Rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-31	Esteici Reyes	stacy0979@gmail.com	Cedar Rapids	Linn	IA	Jeffrey Ventura	Eduardo Contreras	Signed	(1) The employer does not elect the employers’ liability coverage.	Esteici Reyes	stacy0979@gmail.com	Owner	Cedar Rapids	Linn	IA	Jeffrey Ventura	Eduardo Contreras	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
803	2021-12-16 21:47	Anonymous (not verified)	98.21.205.195	Kustom Home Improvements	Proprietorship	400 Davidson St New Virginia Iowa 50210	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-16	Ethan Willett	kustomhomeimprovements.dk@gmail.com	Osceola	Clarke	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed	(1) The employer does not elect the employers’ liability coverage.	David Jack Kimmel	kustomhomeimprovements.dk@gmail.com	Self	New Virginia	Warren	Iowa	Cindy Sue Gyles	Shantell Christine Rice	Signed
194	2020-06-24 15:24	Anonymous (not verified)	173.16.140.254	Eugene Behle	Proprietorship	3134 6th Ave Des Moines IA 50313	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-24	Eugene Behle III	Bub4bme@gmail.com	Des Moines	Polk	Iowa	Kelly Coluzzi	Mitch Coluzzi	Signed	(1) The employer does not elect the employers’ liability coverage.	Eugene Behle III	Bub4bme@gmail.com	Self	Des Moines	POLK	Iowa	Kelly Coluzzi	Mitch Coluzzi	Signed
1364	2022-11-09 09:57	Anonymous (not verified)	50.80.120.38	Egl Enterprises, Inc.	Proprietorship	314 2ND AVE NW	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-09	EUGENE G LARUE	egl.enterprises.inc@gmail.com	HAMPTON	IA	United States	stephanie hofer	aryel laRue	Signed	(1) The employer does not elect the employers’ liability coverage.	EUGENE G LARUE	egl.enterprises.inc@gmail.com	self	HAMPTON	IA	United States	stephanie hofer	aryel laRue	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
1691	2023-06-14 19:20	Anonymous (not verified)	94.188.205.174	Amazing Painting LLC	Limited Liability Company	1301 Boyd Street, Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-14	Evan Michael Regenwether	Evan@amazingpaintingia.com	Des Moines	Polk	Iowa	Austin Matthew Regenwether	Abby Marie Regenwether	Signed	(1) The employer does not elect the employers’ liability coverage.	Evan Michael Regenwether	evan@amaingpaintingia.com	Owner	Des Moines	Polk	Iowa	Austin Matthew Regenwether	Abby Regenwether	Signed
2042	2024-02-12 13:07	Anonymous (not verified)	94.188.205.175	Evelyn R Ventura Terrazas	Proprietorship	524 Terrence	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	Evelyn R Ventura Terrazas	evelynterrazas@gmail.com	Storm Lake	Buena vista	IA	Juan García Oropeza	Karen Rodríguez Pantoja	Signed	(1) The employer does not elect the employers’ liability coverage.	Evelyn R Ventura Terrazas	evelynterrazas@gmail.com	Proprietorship	Storm Lake	Buena vista	IA	Juan Garcia Oropeza	Karen Rodríguez Pantoja	Signed
645	2021-09-18 09:47	Anonymous (not verified)	208.68.114.238	CHL Roofing & Siding Inc	Proprietorship	509 1/2 E A St, West Liberty, IA 52776	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-18	Fabian Galvan Rodriguez	fgalvanglez14@gmail.com	West Liberty	Muscatine	Iowa	Karina A Beltran	Nereida Velez	Signed	(1) The employer does not elect the employers’ liability coverage.	Fabian Galvan Rodriguez	fgalvanglez14@gmail.com	Self	West Liberty	Muscatine	Iowa	Karina A Beltran	Nereida Velez	Signed
736	2021-11-11 14:26	Anonymous (not verified)	72.13.16.172	All Seasons Trucking Inc	Proprietorship	S11689 CTY RD G	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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	FARGEN TRUCKING	dave@allseasonstrucking.com	SPRING GREEN	SAUK	WI	DAVE NEUWOHNER	BEN MOYER	Signed	(1) The employer does not elect the employers’ liability coverage.	FARGEN TRUCKING	DAVE@ALLSEASONSTRUCKING.COM	PRESIDENT	SPRING GREEN	SAUK	WI	Dave Neuwohner	BEN MOYER	Signed
871	2022-01-29 15:43	Anonymous (not verified)	173.31.116.134	West cleaning	Proprietorship	8925 Cascade Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-29	Fata Omerovic	fataomerovic@msn.com	West Des Moines	IA	Iowa	Semir Omerovic	Samir Omerovic	Signed	(1) The employer does not elect the employers’ liability coverage.	Fata Omerovic	fataomerovic@msn.com	Same person	West Des Moines	IA	Iowa	Semir Omerovic	Samir Omerovic	Signed
1836	2023-09-11 09:26	Anonymous (not verified)	94.188.205.174	Felisha Schmitz	Proprietorship	505 Q AVENUE MILFORD IA 51351	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-08	FELISHA SCHMITZ	PETERNFISH@GMAIL.COM	MILFORD	DICKINSON	IA	JENNIFER YOUNGWIRTH	TAMI KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	FELISHA SCMITZ	PETERNFISH@GMAIL.COM	SELF	MILFORD	DICKINSON	IA	JENNIFER YOUNGWIRTH	TAMI KLEIN	Signed
687	2021-10-22 11:07	Anonymous (not verified)	65.144.174.26	Fernando Garcia	Proprietorship	8952 Long Meadow Dr Johnston, IA 50131	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-22	Fernando Garcia	gfernando5030@gmail.com	johnston	polk	Iowa	Javier Manriquez	Josefina Chavez	Signed	(1) The employer does not elect the employers’ liability coverage.	Fernando Garcia	gfernando5030@gmail.com	Owner	Johnston	Polk	Iowa	Javier Manriquez	Josefina Chavez	Signed
1552	2023-04-03 13:58	Anonymous (not verified)	94.188.205.168	F&I Drywall Llc	Limited Liability Company	509 Arlington Dr.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-03	Fernando Garcia	Fgarcia1989.fg@gmail.com	Marshalltown	Marshall	Iowa	Gabriela Garcia	Araceli Tafolla	Signed	(1) The employer does not elect the employers’ liability coverage.	Fernando Garcia	Fgarcia1989.fg@gmail.com	Self	Marshalltown	Marshall	Iowa	Gabriela Garcia	Araceli Tafolla	Signed
2160	2024-04-17 18:21	Anonymous (not verified)	94.188.207.226	QC Remodeling LLC	Limited Liability Company	421 West Broadway, Ste 302 Council Bluffs, IA 51503	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-17	Fernando Ibarra	ibarra_fernando@hotmail.com	Rock Island	Rock Island	Illinois	Paula Barria	Louis Valencia	Signed	(1) The employer does not elect the employers’ liability coverage.	Fernando Ibarra	ibarra_fernando@hotmail.com	Owner	Rock Island	Rock Island	Illinois	Paula Barria	Louis Valencia	Signed
232	2020-08-16 11:28	Anonymous (not verified)	173.27.57.39	Landeros & Sons Construction, Inc	Limited Liability Partnership	1636 19th 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.	2020-08-16	Fernando Landeros	fland1983@gmail.com	Moline	Rock Island	Illinois	Adrian Landeros	Emanuel Landeros	Signed	(1) The employer does not elect the employers’ liability coverage.	Emanuel Landeros	fland1983@gmail.com	Brother	Moline	Rock Island	Illinois	Adrian Landeros	Emanuel Landeros	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
1515	2023-03-13 15:04	Anonymous (not verified)	94.188.207.226	Flint Hillman	Proprietorship	1019 E 17th St, APT 16, Norwalk, IA 50211	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-13	Flint Hillman	flinthillman@gmail.com	Norwalk	Warren	Iowa	Tina Robinson	Paige Robinson	Signed	(1) The employer does not elect the employers’ liability coverage.	Flint Hillman	flinthillman@gmail.com	Self	Norwalk	Warren	Iowa	Tina Robinson	Paige Robinson	Signed
72	2020-02-21 09:43	Anonymous (not verified)	98.18.174.183	Forrest E. Whitford DVM LLC	Limited Liability Company	P.O. Box 120 - 507 Washington Street, Volga, IA 52077	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-21	Forrest E. Whitford, DVM LLC	gfw54@hotmail.com	Volga, IA	Clayton	Iowa	Glenna Whitford	Pam Vaske	Signed	(1) The employer does not elect the employers’ liability coverage.	Forrest E. Whitford, DVM LLC	gfw54@hotmail.com	self	Volga	Clayton	Iowa	Glenna Whitford	Pam Vaske	Signed
2045	2024-02-15 10:26	Anonymous (not verified)	94.188.207.227	Francesco Martinez	Proprietorship	403th 7th Ave NW Clarion IA 50525	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-15	Francesco Martinez	Martinexfrancesco99@gmail.com	Clarion	Wright	Iowa	Jason W Helmers	Josh W Helmers	Signed	(1) The employer does not elect the employers’ liability coverage.	Francesco Martinez	martinezfrancesco99@gmail.com	Employer	Clarion	Wright	Iowa	Jason W Helmers	Josh W Helmers	Signed
1960	2023-12-16 11:58	Anonymous (not verified)	94.188.207.227	Landeros Framing	Proprietorship	2418 E 37th Ct	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-16	Francisco Javier Landeros Garcia	garcialanderosfranciscojavier@gmail.com	Des Moines	IA	IA	Mirna Ruby	Jose Gaytan	Signed	(1) The employer does not elect the employers’ liability coverage.	Francisco Javier Landeros Garcia	garcialanderosfranciscojavier@gmail.com	owner	Des Moines	IA	IA	Mirna Ruby	Jose Gaytan	Signed
2039	2024-02-08 09:25	Anonymous (not verified)	94.188.207.229	Home Re Construction, LLC	Limited Liability Company	5285 NE Mitchell Drive, Mitchellville, IA 50169	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-08	Francisco Miguel Palomares Velasco	homereconstruction@hotmail.com	Mitchellville	Polk	Iowa	Fabiola Palomares Recendiz	Nathan Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Francisco Miguel Palomares Velasco	homereconstruction@hotmail.com	Self	Mithcellville	Polk	Iowa	Fabiola Palomares Recendiz	Nathan Miller	Signed
2187	2024-04-29 08:30	Anonymous (not verified)	94.188.207.226	Fran Stonework LLC	Limited Liability Company	1222 E Seneca Ave Apt 7, Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-29	Francisco Rodriguez Rios	panchito941@icloud.com	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Francisco Rodriguez Rios	panchito941@icloud.com	Self	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed
603	2021-08-14 09:39	Anonymous (not verified)	173.20.168.51	Leaf Filter	Proprietorship	3060 Southeast Grimes Boulevard	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-08-14	Francisco Salgado	fsalgado1989@gmail.com	Perry	IA	United States	Wendy Asturias	Susana Romero	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Leaf Filter	macosta@leafhome.com	none	Grimes	Polk	Iowa	Wendy Asturias	Susana Romero	Signed
493	2021-04-22 08:54	Anonymous (not verified)	66.188.136.150	Frank Lantz	Proprietorship	609 Clinton Street, Charles City, IA 50616	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-21	Frank Lentz	kschumacher@tricorinsurance.com	Charles City	Floyd	IA	Shuree Behr	Mitch Kemp	Signed	(1) The employer does not elect the employers’ liability coverage.	Frank Lantz	kschumacher@tricorinsurance.com	Same	Charles City	Floyd	IA	Shuree Behr	Mitch Kemp	Signed
879	2022-01-31 14:26	Anonymous (not verified)	173.27.146.201	Premier Window Cleaning LLC	Limited Liability Company	420 E GRANGER AVE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-31	Frank Viola	premierofiowa@gmail.com	DES MOINES	IA	United States	Ron Reynolds	Chris Greco	Signed	(1) The employer does not elect the employers’ liability coverage.	Frank Viola	premierofiowa@gmail.com	my self	DES MOINES	IA	United States	Ron Reynolds	Chris Greco	Signed
1601	2023-04-25 14:38	Anonymous (not verified)	94.188.207.230	francisco garcia	Proprietorship	388 lesley ln ne	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-25	franscisco garcia	frasicohinojosa@gmail.com	cedar rapids	linn	iowa	Ryan Klein	Karina Jacobson	Signed	(1) The employer does not elect the employers’ liability coverage.	francisco garcia	frasicohinojosa@gmail.com	N/A	cedar rapids	linn	iowa	Ryan Klein	Karina Jacobson	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
1058	2022-04-19 13:19	Anonymous (not verified)	50.83.154.192	Property Maintenance Services of Iowa LLC	Limited Liability Company	PO Box 166 Low Moor IA 52757	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-19	Frederick Stewart	curlyfry42000@yahoo.com	LOW MOOR	IA	United States	Irene R Stewart	Derek S Jensen	Signed	(1) The employer does not elect the employers’ liability coverage.	Frederick Lee Stewart	zombiesby2012@gmail.com	Owner	Clinton	IA	United States	Irene R Stewart	Derek S Jensen	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
272	2020-10-02 13:10	Anonymous (not verified)	99.203.92.229	Batres Homes Renovation LLC	Limited Liability Company	3000 2nd Ave Des Moines Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-02	Gabriel Antonio Batres Huezo	gabirlebatres7@gmail.com	Des Moines	Polk	Iowa	Blanca Silvia Leiva	Luis Mariano	Signed	(1) The employer does not elect the employers’ liability coverage.	Walter Alexander Batres Huezo	wbatres12@gmail.com	Employer	Des Moines	Polk	Iowa	Blanca Silvia Leiva	Luis Mariano	Signed
447	2021-03-24 14:09	Anonymous (not verified)	208.90.15.53	Gabe Saenz, LLC	Limited Liability Company	PO Box 53 Humboldt, IA 50548	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-24	Gabriel Saenz	gsaenzh@gmail.com	Humboldt	Humboldt	Iowa	Lance DeWinter	Cathy Schipull	Signed	(1) The employer does not elect the employers’ liability coverage.	Gabriel Saenz	gsaenzh@gmail.com	Owner	Humboldt	Humboldt	Iowa	Lance DeWinter	Cathy Schipull	Signed
675	2021-10-15 11:22	Anonymous (not verified)	75.162.156.37	MCG FLOORING, LLC	Limited Liability Company	2115 CARPENTER AVE DES MOINES IA 50311	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-15	GABRIELA GOMEZ	MCGFLOORINGLLC@GMAIL.COM	DES MOINES	USA	IA	YOLANDA MENDOZA	LILIANA SANCHEZ GUTIERREZ	Signed	(1) The employer does not elect the employers’ liability coverage.	MCG FLOORING, LLC	MCGFLOORINGLLC@GMAIL.CON	OWNER	DES MOINES	USA	IA	YOLANDA MENDOZA	LILIANA SANCHEZ GUTIERREZ	Signed
1873	2023-10-20 09:25	Anonymous (not verified)	94.188.207.228	GC Hauling LLC	Limited Liability Company	310 North 18th Street, Indianola, IA, 50125	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-20	Garrett Joseph Claerhout	gjclaerhout@hotmail.com	INDIANOLA	IA	IA	Kirsten Claerhout	Jay Claerhout	Signed	(1) The employer does not elect the employers’ liability coverage.	Garrett Joseph Claerhout	gjclaerhout@hotmail.com	Same Person	INDIANOLA	IA	IA	Kirsten Claerhout	Jay Claerhout	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
867	2022-01-28 12:19	Anonymous (not verified)	207.199.212.86	Gary Elsbernd DBA RGM Dairy Farm	Proprietorship	1538 230th St Calmar IA, 52132	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-21	Gary Elsbernd	lacy@cioia.com	Calmar	Winneshiek	Iowa	Joel Rochford	Lacy Carolan	Signed	(1) The employer does not elect the employers’ liability coverage.	Gary Elsbernd	lacy@cioia.com	Self	Calmar	Winneshiek	Iowa	Joel Rochford	Lacy Carolan	Signed
1735	2023-07-11 08:28	Anonymous (not verified)	94.188.207.229	LBN LLC	Limited Liability Company	1930 se 14th Des Moines Iowa 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-11	Gary Fatino	fatinomarketinggroup@yahoo.com	Des Moines	polk	Iowa	Liana Fatino	Gary Fatino	Signed	(1) The employer does not elect the employers’ liability coverage.	Gary Fatino	fatinomarketinggroup@yahoo.com	owner	des moines	polk	iowa	liana fatino	gary fatino	Signed

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