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:
2058	2024-02-26 16:32	Anonymous (not verified)	94.188.207.224	performance gutter	Proprietorship	PO BOX 306, NORWALK IOWA 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.	2024-02-26	RICHARD BAINTER	RWBNJ50@AOL.COM	NORWALK	WARREN	IOWA	DYLAN LANE	JAMES LANE	Signed	(1) The employer does not elect the employers’ liability coverage.	RICHARD BAINTER	RWBNJ50@AOL.COM	OWNER	NORWALK	WARREN	IOWA	DYLAN LANE	JAMES LANE	Signed
150	2020-05-06 10:59	Anonymous (not verified)	76.190.229.163	RNR Holdings LLC	Limited Liability Company	4330 Winter Eagle Trail SE Apt B, Iowa City, Iowa 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.	2020-05-06	Richard E. White	rwhite245@yahoo.com	Hermitage	Mercer	Pennsylvania	Gene Bell	Victor J Veltri	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard E White	rwhite245@yahoo.com	Owner	Hermitage	Mercer	Pennsylvania	Gene Bell	Victor J Veltri	Signed
2145	2024-04-11 12:27	Anonymous (not verified)	94.188.205.177	Grinnell Web Services LLC	Limited Liability Company	1902 Spring St, Grinnell IA 50112	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.	2024-04-11	Richard Ethington	RDE326@rrmse.com	Grinnell	Poweshiek	Iowa	Lori Stratton	Lisa Folkmann	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard Ethington	rde326@rrmse.com	self	Grinnell	poweshiek	iowa	lori stratton	lisa folkmann	Signed
1045	2022-04-13 09:55	Anonymous (not verified)	192.119.237.126	BARGAIN HOUSE	Proprietorship	11 S FREDERICK AVE, OELWEIN, IA 50662	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.	2022-04-13	RICHARD M. BECKER	SHELBY@CIOIA.COM	HAZLETON	BUCHANAN	IOWA	SHELBY S. WILLIAMS	BOBBIE J. BERGAN	Signed	(1) The employer does not elect the employers’ liability coverage.	RICHARD M. BECKER	SHELBY@CIOIA.COM	OWNER	OELWEIN	FAYETTE	IOWA	SHELBY S. WILLIAMS	BOBBIE J. BERGAN	Signed
776	2021-12-03 10:26	Anonymous (not verified)	192.230.128.72	Richard Makohoniuk	Proprietorship	785 SE Walnut Ridge Dr Waukee, IA. 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-03	Richard Makohoniuk	111@mchsi.com	Waukee	Dallas	Iowa	Tara Makohoniuk	Richard Makohoniuk	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard Makohoniuk	111@mchsi.com	Self	Waukee	Dallas	IA	Tara Makohoniuk	Richard Makohoniuk	Signed
1028	2022-04-02 11:01	Anonymous (not verified)	174.198.64.100	Great-Dain Htg/Ac & Plumbing	Proprietorship	1616 Maple Rd. Harlan, Iowa 51537	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.	2022-04-02	Richard Nee	great-dain@hotmail.com	Harlan	Shelby	Iowa	Doug Clark	Jesse Nee	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard Nee	great-dain@hotmail.com	Self	Harlan	Shelby	Iowa	Doug Clark	Jesse Nee	Signed
1425	2023-01-18 15:20	Anonymous (not verified)	174.228.35.74	Great-Dain Htg/Ac & Plumbing	Proprietorship	1616 Maple Rd Harlan, Iowa 51537	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.	2023-01-18	Richard Presly Nee	great-dain@hotmail.com	Harlan	Shelby	IA	Theresa Clark	Jesse Nee	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard Presley Nee	great-dain@hotmail.com	Self	Harlan	Shelby	IA	Theresa Clark	Jesse Nee	Signed
1396	2022-12-19 18:35	Anonymous (not verified)	174.198.65.20	Flyover Productions LLC	Limited Liability Company	300 S Clinton 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.	2022-12-19	Richard A Redfern	richredfern3@gmail.com	Iowa City	IA	United States	Susan Redfern	Aditi Reddy	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard Redfern	richredfern3@gmail.com	Owner of company	Iowa City	Iowa	United States	Susan Redfern	Aditi Reddy	Signed
689	2021-10-25 14:38	Anonymous (not verified)	107.197.114.249	Brookstin Flooring LLC	Limited Liability Company	1702 Brown Deer Rd Coralville IA 52241	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-10-25	Richard T Klemesrud	rickklemesrud@gmail.com	CORALVILLE	IA	United States	Brian Woods	Sherry Woods	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Richard T Klemesrud	rickklemesrud@gmail.com	Myself / Owner	CORALVILLE	IA	United States	Brian Woods	Sherry Woods	Signed
323	2020-11-19 10:55	Anonymous (not verified)	174.192.67.61	Connor trucking	Proprietorship	2791 270th st Dewitt 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.	2020-11-19	Richard Todd Connor	connortrucking@hotmail.com	Dewitt	Clinton	Iowa	Michelle Connor	Josh connor	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard Todd Connor	connortruckin@hotmail.com	Self	Dewitt	Clinton	Iowa	Michelle Connor	Josh Connor	Signed
716	2021-11-05 13:22	Anonymous (not verified)	209.252.172.87	Rick Clifford Clifford Custom Tile & Flooring	Proprietorship	1563 Palmer Ct NE, Solon, IA 52333	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-24	Rick Clifford	cliffordcustomtile@gmail.com	Solon	Johnson	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Clifford Clifford Custom Tile & Flooring	cliffordcustomtile@gmail.com	Self Employed	Solon	Johnson	Iowa	Sarah Coberley	Heather Howell	Signed
562	2021-07-08 09:46	Anonymous (not verified)	66.188.136.150	Rick Davis	Proprietorship	521 N 13th St. Salina, KS 67401	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-07	Rick Davis	kschumacher@tricorinsurance.com	Salina	Saline	KS	Mitch Kemp	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Davis	kschumacher@tricorinsurance.com	Same	Salina	Saline	KS	Mitch Kemp	Shuree Behr	Signed
1930	2023-12-01 10:20	Anonymous (not verified)	94.188.207.227	TriCounty Enterprises/ DeNeve Construction	Limited Liability Company	5527 Crane Lane 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.	2023-12-01	Rick Delayne Primmer	rdprimmerroofing@gmail.com	Walker	Linn	Iowa	Jerry Wiltsey	Robert Null	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Delayne Primmer	rdprimmerroofing@gmail.com	Worker	Walker	Iowa	Iowa	Jerry Wiltsey	Robert Null	Signed
767	2021-11-22 16:42	Anonymous (not verified)	63.229.189.35	Lakes Custom Bath	Proprietorship	3721 Ithaca Avenue, Spirit Lake IA 51360	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-22	Rick Dykshoorn	abigail@rickmilesartisans.com	SPIRIT LAKE	Dickinson	Iowa	Abigail Miles	Alex Miles	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Dykshoorn	abigail@rickmilesartisans.com	Self	SPIRIT LAKE	Dickinson	Iowa	Abigail Miles	Alex Miles	Signed
720	2021-11-05 13:57	Anonymous (not verified)	209.252.172.87	Rick Klemesrud Brookstin Flooring	Proprietorship	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.	2020-05-23	Rick Klemesrud	installation@bachmeiercarpetone.com	Coralville	Johnson	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Klemesrud	installation@bachmeiercarpetone.com	Self	Croalville	Johnson	Iowa	Heather Howell	Sarah Coberley	Signed
918	2022-02-16 14:23	Anonymous (not verified)	172.58.22.152	RICK MYSAK LLC	Limited Liability Company	2220 GREY WOLF, HIAWATHA, IA 52233	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.	2022-02-16	RICK MYSAK	camysak@gmail.com	Hiawatha	LINN	IOWA	Carrie Mysak	RICK DeNEVE	Signed	(1) The employer does not elect the employers’ liability coverage.	RICK MYSAK	camysak@gmail.com	SELF	Hiawatha	LINN	IOWA	Carrie Mysak	RICK DeNEVE	Signed
1327	2022-10-06 12:23	Anonymous (not verified)	71.39.227.238	RICK OBEREMBT	Proprietorship	1702 SYCAMORE ST, DALLAS CNETER, IA 50063	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-05	RICK OBEREMBT	werock83@gmail.com	DALLAS CENTER	DALLAS	IOWA	ABBEY LUELLEN	DON RICHARDSON	Signed	(1) The employer does not elect the employers’ liability coverage.	RICK OBEREMBT	werock83@gmail.com	SELF	DALLAS CENTER	DALLAS	IOWA	ABBEY LUELLEN	DON RICHARDSON	Signed
856	2022-01-26 13:44	Anonymous (not verified)	69.63.16.2	Rick Peterson	Proprietorship	3366 Lynden Heights Rd 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.	2022-01-26	Richard Peterson	insurancecommercialsam@greenstate.org	Iowa City	Johnson	Iowa	Jonathan Gonzalez	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Peterson	insurancecommercialsam@greenstate.org	Owner	Iowa City	Johnson	IA	Jonathan Gonzalez	Dyan Kriener	Signed
369	2021-01-22 10:02	Anonymous (not verified)	66.188.136.150	Rick Swaney	Proprietorship	1551 Persimmon, Stilwell, OK 74960	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-22	Rick Swaney	kschumacher@tricorinsurance.com	Stilwell	Adair	OK	Russell Masartis	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Swaney	kschumacher@tricorinsurance.com	Same	Stilwell	Adair	OK	Russell Masartis	Shuree Behr	Signed
741	2021-11-11 15:09	Anonymous (not verified)	72.13.16.172	RICK VANGORDER	Proprietorship	2549 QUASQUETON DIAGONAL BLVD	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	RICK VANGORDER	dave@allseasonstrucking.com	INDEPENDENCE	BUCHANAN	IA	Dave Neuwohner	BEN MOYER	Signed	(1) The employer does not elect the employers’ liability coverage.	RICK VANGORDER	dave@allseasonstrucking.com	PRESIDENT	INDEPENDENCE	BUCHANAN	IA	Dave Neuwohner	BEN MOYER	Signed
1165	2022-06-23 09:28	Anonymous (not verified)	74.84.106.106	Rita Littrell	Proprietorship	620 N. 9th St., Carlisle, Iowa 50047	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-23	Rita Littrell	ritaf1966@gmail.com	Carlisle	Warren	Iowa	Kimberly Owens	Tina Owens	Signed	(1) The employer does not elect the employers’ liability coverage.	Rita Littrell	ritaf1966@gmail.com	Self	Carlisle	Warren	Iowa	Kimberly Owens	Tina Owens	Signed
1215	2022-07-20 13:43	Anonymous (not verified)	173.21.133.45	Ottumwa mow & snow LLC	Limited Liability Company	11443 Bladensburg Rd. Ottumwa IA 52501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-20	Lucia A Hughes	lucyh68313@gmail.com	Ottumwa	Wapello	Iowa	Katy Knott	Doug Knott	Signed	(1) The employer does not elect the employers’ liability coverage.	RJ Hallman	rjhallman@fedins.com	Insurance	Owatonna	Steele	Minnesota	Katy Knott	Doug Knott	Signed
1220	2022-07-21 13:12	Anonymous (not verified)	172.58.83.160	Ottumwa mow & snow LLC	Limited Liability Company	11443 Bladensburg Rd. Ottumwa IA 52501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-21	María Duarte	mariacabrera515@icloud.com	Ottumwa	Wapello	Iowa	Katy Knott	Doug Knott	Signed	(1) The employer does not elect the employers’ liability coverage.	RJ Hallman	rjhallman@fedins.com	Insurance	Owatonna	Steele	Minnesota	Katy Knott	Doug Knott	Signed
1225	2022-07-23 18:01	Anonymous (not verified)	174.242.224.34	Ottumwa mow & snow llc	Limited Liability Company	11443 Bladensburg Rd Ottumwa IA 52501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-23	JoAnn laBella	joannlabella@gmail.com	Ottumwa	Wapello	IA	Doug Knott	Katy Knott	Signed	(1) The employer does not elect the employers’ liability coverage.	RJ Hallman	rjhallman@fedins.com	Insurance	Owatonna	Steele	MN	Katy knott	Doug knott	Signed
1226	2022-07-23 18:02	Anonymous (not verified)	174.242.224.34	Ottumwa mow & snow llc	Limited Liability Company	11443 Bladensburg Rd Ottumwa IA 52501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-23	JoAnn laBella	joannlabella@gmail.com	Ottumwa	Wapello	IA	Doug Knott	Katy Knott	Signed	(1) The employer does not elect the employers’ liability coverage.	RJ Hallman	rjhallman@fedins.com	Insurance	Owatonna	Steele	MN	Katy knott	Doug knott	Signed
1361	2022-11-07 09:14	Anonymous (not verified)	65.144.174.26	Rm Tile Marble LLC	Limited Liability Company	2051 King Ave Apt 1, Des Moines, IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-07	Tony Funes	balmore.funes76@icloud.com	Des Moines	Polk	IA	Osman Sarceno Gonzalez	Nelson Hermanez	Signed	(1) The employer does not elect the employers’ liability coverage.	RM Tile Marble LLC	balmore.funes76@icloud.com	Self	Des Moines	Polk	IA	Osman Sarceno Gonzalez	Nelson Hermanez	Signed
860	2022-01-27 11:31	Anonymous (not verified)	69.63.16.2	Dreams 2 Reality Construction LLC	Limited Liability Company	17615 Meredith Dr, Waukee, IA 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-26	Rob Rubsam	rob@dreams2reality.us	Waukee	Dallas	Iowa	Kyle Stahle	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Rob Rubsam	rob@dreams2reality.us	Member	Waukee	Dallas	Iowa	Kyle Stahle	Dyan Kriener	Signed
368	2021-01-21 15:12	Anonymous (not verified)	97.125.235.64	R. A. Snow Removals, Inc	Proprietorship	525 7th St NW, Altoona, IA 50009	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.	2021-01-21	Robert Aaron Snow	rasnowremovals.inc@gmail.com	Altoona	Polk	Iowa	Shannon Keely Moses	Jessy James Dentler	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Aaron Snow	rasnowremovals.inc@gmail.com	President	Altoona	IA	United States	Shannon Keely Moses	Jessy James Dentler	Signed
326	2020-11-25 08:39	Anonymous (not verified)	66.188.136.150	Robert Barbaris	Proprietorship	1104 8th St SE, Cedar Rapids, IA 52401	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-11-25	Robert Barbaris	kschumacher@tricorinsurance.com	Cedar Rapids	Linn	IA	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Barbaris	kschumacher@tricorinsurance.com	Same	Cedar Rapids	Linn	IA	Russell Masartis	Nancy Wortley	Signed
1081	2022-04-29 11:28	Anonymous (not verified)	173.18.22.217	CB's Tree & Lawn Service	Limited Liability Company	593 25th Place Swan IA 50252	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-29	Robert Beau Wittkowski	robertwittkowski1@gmail.com	Swan	Marion	Iowa	Lesa Reeves	William Schuldt	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Beau Wittkowski	robertwittkowski1@gmail.com	Owner	Swan	Marion	Iowa	Lesa Reeves	William Schuldt	Signed
604	2021-08-14 11:18	Anonymous (not verified)	69.54.119.134	Robert Curry	Limited Liability Company	10759 S 96th Ave W Prairie City IA 50228	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.	2021-08-14	Bob Curry	Gardengal4205@gmail.com	Prairie City	IA	United States	Megan Irwin	Rob Irwin	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Curry	Gardengal4205@gmail.com	Self	Prairie City	IA	United States	Megan Irwin	Rob Irwin	Signed
2027	2024-02-07 09:24	Anonymous (not verified)	94.188.207.228	RB SIDING	Proprietorship	P.O. BOX 2034, 310 370TH STREET, LAKE VIEW, IOWA 51450	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-07	ROBERT BELT	bridgetbelt1971@outlook.com	SELF	SAC	IOWA	JOHN CLARENCE OLERICH	NEIL THIESSEN MARTENS	Signed	(1) The employer does not elect the employers’ liability coverage.	ROBERT EUGENE BELT	bridgetbelt1971@outlook.com	SELF	LAKE VIEW	SAC	IOWA	JOHN CLARENCE OLERICH	NEIL THIESSEN MARTENS	Signed
1326	2022-10-04 10:27	Anonymous (not verified)	70.96.153.153	Bright Fame Inc	Limited Liability Company	2185 NW 149th St, Clive, IA 50325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-04	Robert Ferguson	robert@optionsexteriors.com	Clive	Dallas	Iowa	Charlotte Rasmussen	Austin Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Ferguson	robert@optionsexteriors.com	Owner/Self	Clive	Dallas	Iosa	Charlotte Rasmussen	Austin Miller	Signed
444	2021-03-22 16:26	Anonymous (not verified)	207.191.204.10	Robert G. Wright Jr,	Proprietorship	2721 Elm St Dubuque, IA 52001 PO Box 475 Dubuque, IA 52004	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.	2021-03-20	Robert G. Wright Jr,	robertw1963@gmail.com	Dubuque	Dubuque	Iowa	Brian Kregal	Lynda Howell	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert G. Wright Jr,	robertw1963@gmail.com	Owner	Dubuque	Dubuque	Iowa	Brian Kregel	Lynda Howell	Signed
1273	2022-08-19 10:40	Anonymous (not verified)	75.162.65.221	Robert Kilgore	Proprietorship	2404 34th St Des Moines 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.	2022-08-19	Robert Kilgore	robertkilgore1969@gmail.com	Des Moines	Polk	Iowa	Randy Lacine	Laura Lacina	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Kilgore	robertkilgore1969@gmail.com	Self	Des Moines	Polk	Iowa	Randy Lacina	Laura Lacina	Signed
1861	2023-10-05 10:14	Anonymous (not verified)	94.188.207.227	Charles von Maur	Proprietorship	18325 Robbins Road Pleasant Valley IA 52767	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.	2023-10-05	Charles von Maur	rlarsen@vonmaur.com	Pleasant Valley	Scott	IA	Robert L Larsen	Amanda Bratthauer	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert L Larsen	rlarsen@vonmaur.com	Outside consultant	east moline	Rock Island	IL	Josh Barnes	Amanda Bratthauer	Signed
1235	2022-08-01 17:22	Anonymous (not verified)	129.222.1.151	KRG Gutters	Limited Liability Company	20376 Whiskey Rdg Ottumwa, Ia 52501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-01	Robert M Galey	rsgaley24@yahoo.com	Ottumwa	IA	United States	Stacey Galey	Kinnick Galey	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert M Galey	rsgaley24@gmail.com	Self	Ottumwa	IA	United States	Stacey Galey	Kinnick Galey	Signed
1193	2022-07-08 10:18	Anonymous (not verified)	173.18.22.217	OWWT	Limited Liability Company	1915 SE Clovere Ridge 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.	2022-07-08	Robert M Jackson	dgfl08051982@gmail.com	Ankeny	Polk	IA	Lesa Reeves	Erick Schuldt	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert M Jackson	dgfl08051982@gmail.com	Owner	Ankeny	Polk	Iowa	Lesa Reeves	Erick Sculdt	Signed
2082	2024-03-08 10:47	Anonymous (not verified)	94.188.205.176	T & S Sandblastin and Painting LLC	Limited Liability Company	101 Clinton ST Corwith IA 50430	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-08	Robert Schissel	matt.tindall83@gmail.com	Corwith	Hancock	Iowa	Wendy S Jensen	Jason Bradley	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Schissel	matt.tindall83@gmail.com	self	Corwith	Hancock	Iowa	Wendy S Jensen	Jason Bradley	Signed
2227	2024-05-16 11:05	Anonymous (not verified)	94.188.207.227	Ver Steegh Building	Proprietorship	1660 305th St, Eddyville, IA 52553	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	Robert Scott Ver Steegh	rsversteegh@gmail.com	Eddyville	Mahaska	Iowa	Brad Terpstra	Robert Hallman	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Scott Ver Steegh	rsversteegh@gmail.com	Self	Eddyville	Mahaska	Iowa	Brad Terpstra	Robert Hallman	Signed
489	2021-04-20 13:47	Anonymous (not verified)	69.63.16.2	Mow-n-Mor Lawn & Landscaping LLC	Limited Liability Company	2585 500th St SW, Kalona, IA 52247	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.	2021-04-19	Robert Sieren	mtesdell@yahoo.com	Kalona	Johnson	Iowa	Scott Freeman	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Sieren	mtesdell@yahoo.com	Managing Member	Kalona	Johnson	Iowa	Scott Freeman	Dyan Kriener	Signed
1433	2023-01-27 13:24	Anonymous (not verified)	184.97.152.214	Rwdcarpet	Proprietorship	4927 cedarbrook drive	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.	2023-01-27	Robert Wayne Durand iii	rwdcarpet24@gmail.com	Council bluffs	Pottawattamie	Iowa	Kitty whissinand	Kelley durand	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Wayne Durand iii	rwdcarpet24@gmail.com	Self	Council bluffs	Pottawattamie	Iowa	Kitty whissinand	Kelley Durand	Signed
575	2021-07-14 14:01	Anonymous (not verified)	69.57.205.10	Robert W. Cantrell	Proprietorship	845 East Redwood Circle, Hanford, CA 93230	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-10	Robert Wescott Cantrell	rcr4@comcast.net	Hanford	Kings	CA	Shirley J. Loney	Joel L. Meyer	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Westcott Cantrell	rcr4@comcast.net	proprietor	Hanford	Kings	CA	Shirley J. Loney	Joel L. Meyer	Signed
1224	2022-07-23 14:14	Anonymous (not verified)	69.57.205.10	Robert W. Cantrell	Proprietorship	845 East Redwood Circle, Hanford, CA 93230	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-23	Robert Wescott Cantrell	marquisaviationinc@yahoo.com	Hanford	Kings	CA	Shirley J. Loney	Joel L. Meyer	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Westcott Cantrell	marquisaviationinc@yahoo.com	proprietor	Hanford	Kings	CA	Shirley J. Loney	Joel L. Meyer	Signed
2118	2024-03-27 13:25	Anonymous (not verified)	94.188.207.223	Zaragoza Home Solutions LLC	Limited Liability Company	1644 E Walnut St. Des Moines IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-27	Roberto C. Curiel	zaragozahomesolutionsllc@gmail.com	Des Moines	Polk	Iowa	Fabiola Palomares Recendiz	Francisco A Palomares Zepeda	Signed	(1) The employer does not elect the employers’ liability coverage.	Roberto C Curiel	zaragozahomesolutionsllc@gmail.com	Self	Des Moines	Polk	Iowa	Fabiola Palomares Recendiz	Francisco A Palomares Zepeda	Signed
988	2022-03-21 10:40	Anonymous (not verified)	173.27.156.183	JABS Construction/Finish	Limited Liability Company	543 10th Ave. S.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-20	Roberto John Henrickson	henricksonroberto10@gmail.com	Clinton	IA	United States	N/A	N/a	Signed	(1) The employer does not elect the employers’ liability coverage.	Roberto John Henrickson	henricksonroberto10@gmail.com	Owner	Clinton	IA	United States	N/A	N/A	Signed
989	2022-03-21 10:40	Anonymous (not verified)	173.27.156.183	JABS Construction/Finish	Limited Liability Company	543 10th Ave. S.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-20	Roberto John Henrickson	henricksonroberto10@gmail.com	Clinton	IA	United States	N/A	N/a	Signed	(1) The employer does not elect the employers’ liability coverage.	Roberto John Henrickson	henricksonroberto10@gmail.com	Owner	Clinton	IA	United States	N/A	N/A	Signed
2138	2024-04-05 12:30	Anonymous (not verified)	94.188.205.167	Joseph L Neighbors dba J L N Trucking	Proprietorship	5466 18th Ave Mount Auburn IA 52313	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-05	Joseph L Neighbors	robynne@cmbrown.net	Mount Auburn	Benton	Iowa	Sarah Svehla	Angela Vangennip	Signed	(1) The employer does not elect the employers’ liability coverage.	Robynne Dawn Duvall	robynne@cmbrown.net	insurance agent	Perryville	Missouri	Missouri	Sarah Svehla	Angela Vangennip	Signed
1768	2023-07-29 11:10	Anonymous (not verified)	94.188.207.223	Makana Industries LLC	Limited Liability Company	1800 Grand Ave #352, West Des Moines, IA 50265	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.	2023-07-29	Matthew Akana	mandiremod515@gmail.com	West Des Moines	Polk	Iowa	Catherine Sobrado	James Fowler	Signed	(1) The employer does not elect the employers’ liability coverage.	Rocket Lawyer Corporate Services LLC	mandiremod515@gmail.com	Registered agent	Des Moines	Polk	Iowa	Catherine Sobrado	James Fowler	Signed
1409	2023-01-05 11:55	Anonymous (not verified)	173.23.88.7	Top tier gutter systems llc	Limited Liability Company	405a 1st Ave sw Cedar Rapids, ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-05	Rocky layne smith	toptierguttersystems@yahoo.com	Cedar Rapids	Linn	IA	Faye momodu	Rocky smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Rocky smith	toptierguttersystems@yahoo.com	Self	Cedar Rapids	Linn	IA	Faye momodu	Derrick	Signed

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