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:
1151	2022-06-13 09:29	Anonymous (not verified)	208.126.52.58	Ronald D. Heneke	Proprietorship	PO Box 114	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.	2022-06-13	Ronald D. Heneke	rheneke@email.com	Delmar	Clinton	Iowa	Mary S. O’Dell	Neal J. Damm	Signed	(1) The employer does not elect the employers’ liability coverage.	Ronald D. Heneke	rheneke@email.com	Self	Delmar	Clinton	Iowa	Mary S. O’Dell	Neal J. Damm	Signed
1444	2023-02-07 14:57	Anonymous (not verified)	173.21.126.4	Rhino Roofing	Limited Liability Company	2534 Garfield 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.	2021-02-07	Irwins Martinez	rhinoroofingsiding21@gmail.com	Des Moines	Polk	Iowa	Sara Titus	Justin Williams	Signed	(1) The employer does not elect the employers’ liability coverage.	Irwin Martinez	rhinoroofing21@gmail.com	Self	Des Moines	Polk	Iowa	Sara Titus	Justin Williams	Signed
151	2020-05-07 15:57	Anonymous (not verified)	198.167.182.164	Hawk-I Trucking LLC	Limited Liability Company	521 Greenfield Dr, Tiffin, IA 52340	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-06	Chad Lee Freeman	ricenogle@southslope.net	Tiffin	Johnson	IA	Scott Freeman	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Chad Lee Freeman	ricenogle@southslope.net	Managing Member	Tiffin	Johnson	IA	Scott Freeman	Dyan Kriener	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
1342	2022-10-25 09:02	Anonymous (not verified)	174.240.251.79	Mahieu excavation	Proprietorship	6140 n Lincoln ave Davenport iowa 52806	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-25	Joshua j Mahieu	ridinmytrain2@gmail.com	Davenport	Scott	Iowa	Mike Leon	Joseph Koranda	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua j Mahieu	ridinmytrain2@gmail.com	Owner	Davenport	Scott	Iowa	Mike Leon	Joseph Koranda	Signed
2218	2024-05-09 16:20	Anonymous (not verified)	94.188.205.167	Brenda Riseley	Proprietorship	2265 Copper Wynd Drive, Pleasant Hill Iowa 50327	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.	2024-05-09	Brenda Riseley	riseleybrenda@gmail.com	Pleasant Hill	IA	United States	Brenda Riseley	Brenda Riseley	Signed	(1) The employer does not elect the employers’ liability coverage.	Brenda Riseley	riseleybrenda@gmail.com	Self	Pleasant Hill	IA	United States	David Bottino	Aubrey Stith	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
1282	2022-08-25 06:51	Anonymous (not verified)	63.240.136.241	River City Property Services LLC.	Limited Liability Company	1936 9th 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.	2022-08-25	Brandon Smith	RiverCityPropertyServices@outlook.com	Camanche	Iowa	United States	Sarah Smith	MIke Burmahl	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandon Smith	RiverCityPropertyServices@outlook.com	Partner	Camanche	Iowa	United States	Sarah Smith	MIke Burmahl	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
2095	2024-03-14 11:39	Anonymous (not verified)	205.221.255.62	Trimble Lawncare And Landscaping	Proprietorship	215 Boundary Ave Middletown IA 52638	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.	2024-03-14	Kevin Blake Trimble	rknhtrimble@yahoo.com	Middletown	Des Moines	Iowa	Katelyn Orth	Shayla Taeger	Signed	(1) The employer does not elect the employers’ liability coverage.	Kevin Blake Trimble	rknhtrimble@yahoo.com	owner	Middletown	Des Moines	Iowa	Katelyn Orth	Shayla Taeger	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
199	2020-07-09 10:49	Anonymous (not verified)	167.142.98.40	Ryan Stott	Proprietorship	1513 Hawthorne Lane	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-09	Ryan Lynn Stott	rlstott@hotmail.com	Jefferson	Greene	Iowa	Brock Chisum	Brian Chisum	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Stott	rlstott@hotmail.com	self	Jefferson	Greene	Iowa	Brock Chisum	Brian Chisum	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
187	2020-06-15 11:55	Anonymous (not verified)	67.60.42.173	SANDS CONSTRUCTION LLC	Limited Liability Company	3812 Sioux River Rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2020-06-15	Ryan Sands	rn_sands@hotmail.com	Sioux City	IA	IA	Nicole Sands	Reese Sands	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Ryan Sands	rn_sands@hotmail.com	self/ Owner/ Operator	Sioux City	IA	IA	Nicole Sands	Reese Sands	Signed
188	2020-06-15 11:55	Anonymous (not verified)	67.60.42.173	SANDS CONSTRUCTION LLC	Limited Liability Company	3812 Sioux River Rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2020-06-15	Ryan Sands	rn_sands@hotmail.com	Sioux City	IA	IA	Nicole Sands	Reese Sands	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Ryan Sands	rn_sands@hotmail.com	self/ Owner/ Operator	Sioux City	IA	IA	Nicole Sands	Reese Sands	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
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
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
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
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
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
2164	2024-04-19 13:52	Anonymous (not verified)	94.188.205.167	RKB Designs LLC	Limited Liability Company	4333 Cedar St, Davenport, IA 52806	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-19	Ashley Rocca	roccafive@gmail.com	Davenport	IA	United States	Nicholas Rocca	Joni Long	Signed	(1) The employer does not elect the employers’ liability coverage.	Ashley Rocca	roccafive@gmail.com	Self	Davenport	IA	United States	Nicholas Rocca	Joni Long	Signed
962	2022-03-09 16:45	Anonymous (not verified)	207.199.231.172	Thomas Whitehead	Proprietorship	1602 Green St Oskaloosa, IA 52577	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.	2022-03-09	Thomas Whitehead	roctomjj@mahaska.org	Oskaloosa	Mahaska	Iowa	James Anderson	Ashley Bryan	Signed	(1) The employer does not elect the employers’ liability coverage.	Thomas Whitehead	roctomjj@mahaska.org	Self	Oskaloosa	Mahaska	Iowa	James Anderson	Ashley Bryan	Signed
898	2022-02-04 21:46	Anonymous (not verified)	107.77.161.27	Roger De La Rosa	Proprietorship	2104 E 25th St Des Moines IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-04	Roger De La Rosa	roger_dlr72@yahoo.com	Des Moines	Polk	IA	Noreen Henry	Christian Lopez	Signed	(1) The employer does not elect the employers’ liability coverage.	Roger De La Rosa	roger_dlr72@yahoo.com	Owner	Des Moines	Polk	IA	Noreen Henry	Christian Lopez	Signed
690	2021-10-26 14:23	Anonymous (not verified)	65.144.174.26	Santiago Rojas	Proprietorship	1359 22nd st 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.	2021-10-26	Santiago Rojas	rojassr09@gmail.com	Des Moines	Polk	Iowa	David Rojas	Beatriz Hernandez	Signed	(1) The employer does not elect the employers’ liability coverage.	Santiago Rojas	rojassr09@gmail.com	Owner	Des Moines	Polk	Iowa	David Rojas	Beatriz Hernandez	Signed
2075	2024-03-05 22:32	Anonymous (not verified)	94.188.207.225	Steve Roland Trucking LLC	Limited Liability Company	2141 Wadsley Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-05	Steve Roland	roland.farms@yahoo.com	Sac City	IA	United States	Caylee Hoffard	Kristen Wirtjers	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Roland	roland.farms@yahoo.com	Owner/Member	Sac City	IA	United States	Caylee Hoffard	Kristen Wirtjers	Signed
2076	2024-03-05 22:38	Anonymous (not verified)	94.188.207.229	Steve Roland Trucking LLC	Limited Liability Company	2141 Wadsley Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-05	Steve Roland	roland.farms@yahoo.com	Sac City	Sac	Iowa	Caylee Hoffard	Kristen Wirtjers	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Roland	roland.farms@yahoo.com	Owner/Member	Sac City	Sac	Iowa	Caylee Hoffard	Kristen Wirtjers	Signed
1118	2022-05-18 11:12	Anonymous (not verified)	174.215.249.55	Nilson construction	Proprietorship	3219 bowdoin st Des Moines Iowa 50313	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-18	Romel Edenilson saravia Aparicio	romelsaravia5@gmail.com	Des Moines	Polk	Iowa	Alvaro camacho	Ricardo Iyan campuzano	Signed	(1) The employer does not elect the employers’ liability coverage.	Romel edenilson saravia aparicio	romelsaravia5@gmail.com	Employer	Des Moines	Polk	Iowa	Alvaro camacho	Ricardo iyan campuzano	Signed
1781	2023-08-03 21:23	Anonymous (not verified)	94.188.205.166	Ron Peiffer Machine	Limited Liability Company	139 S 1st St Harpers Ferry, Ia 52146	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-03	Ron Peiffer	ron@rpeiffer.com	Harpers Ferry	Allamakee	Iowa	Marie Burington	Cassie Bakke	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron Peiffer	ron@rpeiffer.com	myself- SOLE PROPRIETOR	Harpers Ferry	Allamakee	Iowa	Marie Burington	Cassie Bakke	Signed
2088	2024-03-12 10:44	Anonymous (not verified)	94.188.207.226	Elmer Henry Vicente Lopez	Proprietorship	1602 Court St Apt 2 Sioux City, IA 51105	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	Elmer Henry Vicente Lopez	vicenteelmer33@gmail.com	Sioux City	Woodbury	Iowa	Adrian Dominguez	Ronald Halverson	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron Halverson	ron@sppinsurance.com	independent contractor	Cherokee	Cherokee	IA	Elmer Henry Vicente Lopez	Ronald Halverson	Signed
2090	2024-03-12 14:16	Anonymous (not verified)	94.188.205.169	Oscar Sosa	Proprietorship	110 E Cherry St Cherokee, IA 51012	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	Oscar Sosa	oscarsosa@live.com	Cherokee	Cherokee	Iowa	Adrian Dominguez	Ronald Halverson	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron Halverson	ron@sppinsurance.com	independent contractor	Cherokee	Cherokee	IA	Oscar Sosa	Ronald Halverson	Signed
837	2022-01-13 08:38	Anonymous (not verified)	169.197.65.8	Reyes Concrete Services llc	Limited Liability Company	101 Perry St South Jesup, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-13	Ronald Reyes	ronlreyes1975@gmail.com	Jesup	Buchanan	Iowa	Jacolin Reyes	Ronald Reyes	Signed	(1) The employer does not elect the employers’ liability coverage.	Ronald Reyes	ronlreyes1975@gmail.com	Same	Jesup	Buchanan	Iowa	Jacolin Reyes	Ronald Reyes	Signed
683	2021-10-20 09:39	Anonymous (not verified)	173.23.253.122	Superior Floors	Limited Liability Company	704 41st Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-20	Ron Shannon	ronshannon3831@gmail.com	West Des Moines	IA	United States	Virginia Shannon	Virginia Shannon	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron Shannon	ronshannon3831@gmail.com	Self	West Des Moines	IA	United States	Virginia Shannon	Virginia Shannon	Signed
824	2022-01-06 20:57	Anonymous (not verified)	209.252.175.92	Rottweiler Remodel & Repair LLC	Limited Liability Company	1503 10th Ave Sw Cedar Rapids 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.	2022-01-06	Zechariah Robert DeLaVergne	rottweilerremodel@gmail.com	Cedar Rapids	Linn County	Iowa	Kathy Maxine Morgan	Daisha Rae Gonzalez	Signed	(1) The employer does not elect the employers’ liability coverage.	Zechariah DeLaVergne	rottweilerremodel@gmail.com	Owner	Cedar Rapids	Linn County	Iowa	Kathy Maxine Morgan	daisha rae gonzalez	Signed
891	2022-02-03 15:25	Anonymous (not verified)	173.23.180.117	Roy Dawson	Proprietorship	2602 Green Creek, 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.	2022-02-03	Roy Dawson	roydawson19@gmail.com	Cedar Falls	Black Hawk County	Iowa	Nickole Pry	Christine Willis	Signed	(1) The employer does not elect the employers’ liability coverage.	Roy Dawson	roydawson19@gmail.com	Same person	Cedar Falls	Black Hawk	Iowa	Nickole Pry	Christine Willis	Signed
858	2022-01-27 08:06	Anonymous (not verified)	75.162.81.119	MR Custom Tile & Flooring LLC	Limited Liability Company	14390 Newbold 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.	2022-01-27	Matthew Royer	royer20@yahoo.com	Indianola	Warren	United States	Leiloni Royer	Elena Royer	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Royer	royer20@yahoo.com	Myself	Indianola	Warren	United States	Leiloni Royer	Elena Royer	Signed
1842	2023-09-14 14:08	Anonymous (not verified)	94.188.205.174	RM Construction	Limited Liability Company	1623 120th Street, Hazleton, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-14	Roy Miller	roymiller@aol.com	Hazleton	Buchanan	Iowa	Steve Frost	Julie Schick	Signed	(1) The employer does not elect the employers’ liability coverage.	Roy Miller	roymiller@aol.com	self	Hazleton	Buchanan	Iowa	Steve Frost	Julie Schick	Signed
1860	2023-10-04 14:31	Anonymous (not verified)	94.188.207.229	Raymond Osbon	Proprietorship	1634 Park Towne 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.	2023-10-04	Raymond Earl Osbon	rozbon999@gmail.com	Cedar Rapids	Linn	Iowa	Brandon Gibbs	Jamie Fisher	Signed	(1) The employer does not elect the employers’ liability coverage.	Raymond Earl Osbon	rozbon999@gmail.com	Myself	Cedar Rapids	Linn	Iowa	Brandon Gibbs	Jamie Fisher	Signed
1135	2022-05-31 12:06	Anonymous (not verified)	174.215.227.133	Plagman Transportation	Limited Liability Company	1306 Main St, Adel, Ia. 50003	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.	2022-05-31	Ryan Plagman	rplagman@gmail.com	Adel	Dallas	Ia	Chris Christensen	Jack Ruby	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Plagman	rplagman@gmail.com	Same	Adel	Dallas	Ia	Chris Christensen	Jack Ruby	Signed
1457	2023-02-15 18:06	Anonymous (not verified)	94.188.205.166	Chad Cowan	Limited Liability Company	2108 Locust St 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.	2023-02-15	Chad Stuart Cowan	chad@bigroofing515.com	West Des Moines	Polk	Iowa	Paul Mouw	Rob Schultz	Signed	(1) The employer does not elect the employers’ liability coverage.	Chad Cowan	rr2cw@yahoo.com	Same	West Des Moines	IA	United States	Paul Mouw	Rob Schultz	Signed
1491	2023-03-03 11:24	Anonymous (not verified)	94.188.207.224	Ray gist	Proprietorship	4330 nw 9th st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-03	Raymond Rex Gist	rrgist8@yahoo.com	Dsm	Polk	Ia	Amber Gist	Victor Brawdy	Signed	(1) The employer does not elect the employers’ liability coverage.	Raymond Rex Gist	rrgist8@yahoo.com	Same person	Dsm	Polk	Ia	Amber Gist	Victor Brawdy	Signed
425	2021-03-05 16:03	Anonymous (not verified)	65.103.82.36	Ryan Richard	Proprietorship	1425 W 34th Street, Davenport IA 52806	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-15	Ryan Richard	RRichard@gmail.com	Davenport	Scott	Iowa	Dawn Tague	Eric Johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Richard	RRichard@gmail.com	Self	Davenport	Scott	Iowa	Dawn Tague	Eric Johnson	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
2215	2024-05-08 22:07	Anonymous (not verified)	94.188.207.223	Self Employed-Ryan Thornton	Proprietorship	8403 Horton Ave Urbandale IA 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-08	Ryan M Thornton	rt6366155@gmail.com	Urbandale	Polk	Iowa	April Oxendale	Bruce Thornton	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Thornton	rt6366155@gmail.com	Self	Urbandale	Polk	Iowa	April Oxendale	Bruce Thornton	Signed
1834	2023-09-08 15:04	Anonymous (not verified)	94.188.205.177	Ryan Tucker	Proprietorship	19000 hwy 69	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	Ryan Tucker	rtlltucker@yahoo.com	Indianola	Warren	Iowa	Brooke Prior	Aly Brose	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Tucker	rtlltucker@yahoo.com	Officer	Indianola	Warren	Iowa	Brooke Prior	Aly Brose	Signed
1797	2023-08-14 09:37	Anonymous (not verified)	94.188.205.175	SCG	Limited Liability Company	307 Bridge St. Redfield, IA 50233	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-01	David Dwight Willis	d.dubbaits@yahoo.com	Redfield	Dallas	Iowa	Lindsey Willis	Sam Samuelson	Signed	(1) The employer does not elect the employers’ liability coverage.	Ross Turner	RTurner@holmesmurphy.com	Agent	Waukee	Dallas	Iowa	Brain Paterson	Brandon DeGroff	Signed

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