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:
1816	2023-08-23 14:59	Anonymous (not verified)	94.188.207.227	CHRIS PIERCE CONSTRUCTION LLC	Proprietorship	500 N 8th StAkron, IA 5100	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.	2023-08-23	Chris Pierce	chrispierceconstructionllc@gmail.com	Akron	Plymouth	IA	Susan Geist	Paychex Insurance Agency	Signed	(1) The employer does not elect the employers’ liability coverage.	Susan Geist	sgeist@paychex.com	Insurance Agency	Rochester	Monroe	NY	Susan Geist	Paychex Insurance Agency	Signed
25	2020-01-03 13:09	Anonymous (not verified)	74.84.121.206	Raymond Jones	Proprietorship	P O Box 682 Monona IA 52159	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-11-29	Raymond Jones	darrele@ciains.biz	Monona	Clayton	Iowa	Darrel J Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Darrel J Elsbernd	darrele@ciains.biz	insurance agent	Lime Springs	Howard	Iowa	Darrel J Elsbernd	Chris Fye	Signed
182	2020-06-11 14:18	Anonymous (not verified)	173.29.64.73	Diamond Builders of Davenport INC	Proprietorship	14358 275th St, Long grove, IA 52756	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.	2020-06-11	Paula Woods	paulawoods@diamond-builders.com	Long Grove	IA	United States	Colin Woods	Joe Roozeboom	Signed	(1) The employer does not elect the employers’ liability coverage.	Tyler Green	tyler@porterinsuranceinc.com	Insurance Agent	Long Grove	IA	United States	Colin Woods	Joe Roozeboom	Signed
246	2020-08-25 15:36	Anonymous (not verified)	97.125.173.2	MPT plumbing	Limited Liability Company	4616 147th st urbandale, ia 50323	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-25	justin lee tigges	tplumbing3@aol.com	urbandale	dallas	iowa	insurance is a scam	I would get a different issurance company	Signed	(1) The employer does not elect the employers’ liability coverage.	grinnell mutual	lori@grinnellmutual.com	insurance agent	i dont know	I don't know	iowa	what a pain in the ass	This makes no sense	Signed
412	2021-02-23 14:23	Anonymous (not verified)	205.185.135.176	Jeffrey Meyer	Proprietorship	118 1st St SE New Albin IA 52160	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.	2021-02-23	Jeffrey Meyer	meyertimberservices@gmail.com	New Albin	Allamakee	Iowa	Michael Klug	Kayla Snitker	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Klug	mike@aibme.com	Insurance Agent	Caledonia	Houston	Minnesota	Jeffrey Meyer	Kayla Snitker	Signed
452	2021-03-26 07:30	Anonymous (not verified)	173.31.109.49	Rogers Concrete Construction	Partnership	22802 County Rd E34	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.	2021-03-26	Alexander Olah	aolah43@gmail.com	Cedar Rapids	Linn	Iowa	Robin Marie Kane	Augies Rodrigez	Signed	(1) The employer does not elect the employers’ liability coverage.	Kevin Johnson	kevinjohnson@libertymutual.com	Insurance Agent	Appleton	Outagamie	Wisconsin	Robin Marie Kane	Augie Rodrigez	Signed
464	2021-04-07 22:15	Anonymous (not verified)	173.18.251.105	TEMPLEMAN LAWN CARE AND SNOW REMOVAL	Proprietorship	1612 Lomas Circle	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.	2021-04-07	TIM LEE Templeman	nancytempleman@gmail.com	Atlantic	IA	United States	TARA JESSEN	ALFRED WEDE	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	CULLEN AND ASSOCIATES	tammy@cullenins.com	Insurance agent	Atlantic	Cass	Iowa	Tara Jessen	Alfred Wede	Signed
839	2022-01-14 10:56	Anonymous (not verified)	173.29.218.216	Midwest Solar Services, LLC	Limited Liability Company	595 Huff Street, Dubuque, IA 52003	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.	2022-01-10	Tyler Billmeyer	tbillmeyer@midwestsolarservices.com	Dubuque	Dubuque	Iowa	Kim Esser	Michelle Huss	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Midwest Solar Services, LLC	kim.esser@kunkel-inc.com	Insurance Agent	Dubuque	Dubuque	Iowa	Kim Esser	Michelle Huss	Signed
840	2022-01-14 10:58	Anonymous (not verified)	173.29.218.216	Midwest Solar Services, LLC	Limited Liability Company	595 Huff Street, Dubuque, IA 52003	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.	2022-01-10	Matthew Shear	mshear@midwestsolarservices.com	Dubuque	Dubuque	Iowa	Kim Esser	Michelle Huss	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Midwest Solar Services, LLC	kim.esser@kunkel-inc.com	Insurance Agent	Dubuque	Dubuque	Iowa	Kim Esser	Michelle Huss	Signed
841	2022-01-14 15:23	Anonymous (not verified)	173.29.218.216	Midwest Solar Services, LLC	Limited Liability Company	595 Huff Street, Dubuque, IA 52003	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.	2022-01-10	Matthew Shear	mshear@midwestsolarservices.com	Hanover	Jo Daviess	IL	Kim Esser	Michelle Huss	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Midwest Solar Services, LLC	kim.esser@kunkel-inc.com	Insurance Agent	Dubuque	Dubuque	Iowa	Kim Esser	Michelle Huss	Signed
955	2022-03-08 11:21	Anonymous (not verified)	166.181.80.171	JB Roofing & Home Repair	Limited Liability Company	453 South Street Kalona, 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.	2022-03-08	Jason Boller	jbroofhr@gmail.com	Kalona	Washington	IA	Jodee Stransky	Christian Swartzentruber	Signed	(1) The employer does not elect the employers’ liability coverage.	Christian Swartzentruber	christian@fisherins.com	Insurance Agent	Kalona	Washington	IA	Jodee Stransky	Christian Swartzentruber	Signed
1037	2022-04-07 08:16	Anonymous (not verified)	104.207.27.18	SION LUTHERAN CHURCH	Proprietorship	4525 FINCH AVE LAKE MILLS, IA 50450	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.	2021-03-07	JANE BRUNSVOLD	janebrunsvold@yahoo.com	LAKE MILLS	WINNEBAGO	IOWA	ANDREW STENSRUD	JILL FLUGUM	Signed	(1) The employer does not elect the employers’ liability coverage.	ANDREW STENSRUD	ANDREW@STENSRUDINSURANCE.COM	INSURANCE AGENT	LAKE MILLS	WINNEBAGO	IOWA	JANE BRUNSVOLD	JILL FLUGUM	Signed
1216	2022-07-20 16:24	Anonymous (not verified)	208.38.231.24	Leaf Filter	Limited Liability Partnership	866 40th ave Bettendorf IA 52722	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-19	Savannah Taets	savannahtaets@gmail.com	Davenport	Scott	Iowa	Savannah Taets	Layman Miller	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jennifer Stricklett	jennifer.stricklett@suracy.com	Insurance agent	Davenport	Scott	Iowa	Savannah Taets	Layman Miller	Signed
1475	2023-02-21 18:42	Anonymous (not verified)	94.188.207.230	Michael Goodyk Consgtruction	Proprietorship	2392 Keokuk Drive Pella, Iowa. 50219	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.	2023-02-20	Michael Jay Goodyk	mikegoodyk@gmail.com	Pella	Marion	Iowa	Joy Ekloffe	Rick Ekloffe	Signed	(1) The employer does not elect the employers’ liability coverage.	Gorp Edwards insurance	bwilliams@vangorpins.com	Insurance Agent	Pella	Marion	Iowa	Joy Ekloffe	Rick Ekloffe	Signed
1496	2023-03-06 11:24	Anonymous (not verified)	94.188.207.227	Carrillo Drywall, LLC	Limited Liability Company	119 Marsh 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.	2023-03-06	Yesenia Carrillo	yesecarrillo84@gmail.com	Waterloo	IA	United States	Rene Carrillo Jr	Martha Basurto	Signed	(1) The employer does not elect the employers’ liability coverage.	Kyle Hildman	kyleh@sinnottagency.com	Insurance Agent	Waterloo	IA	United States	Rene Carrillo Jr	Martha Basurto	Signed
1689	2023-06-13 19:55	Anonymous (not verified)	94.188.207.227	Gerardo Reyes-Lopez	Limited Liability Company	908 West 1st Street, Waterloo, IA ,50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-13	Gerardo Reyes-lopez	greyeslopez9@gmail.com	Waterloo	Black Hawk	Iowa	Guillermina Lopez	Bernardo Reyes	Signed	(1) The employer does not elect the employers’ liability coverage.	Denise Seitsinger	denise@harmsinsuranceagency.com	Insurance Agent	Sumner	Bremer	Iowa	Gerardo Reyes	Bernardo Reyes	Signed
1690	2023-06-13 20:01	Anonymous (not verified)	94.188.207.227	Gerardo Reyes-Lopez	Limited Liability Company	908 West 1st Street, Waterloo, Iowa, 50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-13	Gerardo Reyes-lopez	bernardo@reyesconstruct.com	Waterloo	IA	United States	Guillermina Lopez	Bernardo Reyes	Signed	(1) The employer does not elect the employers’ liability coverage.	Denise Seitsinger	denise@harmsinsuranceagency.com	Insurance Agent	Sumner	Bremer	Iowa	Gerardo Reyes	Bernardo Reyes	Signed
2008	2024-01-29 14:45	Anonymous (not verified)	94.188.207.230	DB2P	Limited Liability Company	5904 Ashworth Road	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.	2024-01-29	Arjun Dahal	allcoolliquors@gmail.com	West Des Moines	Dallas	Iowa	Jayson Jones	Nikki Wilks	Signed	(1) The employer does not elect the employers’ liability coverage.	Jayson Jones	jayson@jonesinsured.com	Insurance Agent	Urbandale	Dallas	Iowa	Jayson Jones	Nikki Wilks	Signed
2134	2024-04-04 08:10	Anonymous (not verified)	94.188.205.169	TERRA CONSTRUCTION LLC	Limited Liability Company	621 Oak Park Ave Des Moines, IA 50313	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2024-04-04	Bryce Shabazz	block.radio@yahoo.com	Des Moines	Polk	Iowa	Megan Donigan	George Hana	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jessica L Heller	Jessica.heller@adp.com	Insurance Agent	Allentown	Lehigh	PA	Megan Donigan	George Hana	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
606	2021-08-17 12:25	Anonymous (not verified)	69.57.199.231	Precision Painting	Proprietorship	507 Broad 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.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-08-17	Daniel Paul Bowser	danshonda12@gmail.com	Reinbeck	Grundy	Iowa	David Paul Bowser	Mary Ellen Sue Bowser	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Sinnott Agency	toms@sinnottagency.com	Insurance provider	Waterloo	Blackhawk	Iowa	David Paul Bowser	Mary Ellen Sue Bowser	Signed
607	2021-08-17 12:31	Anonymous (not verified)	69.57.199.231	Precsion Painting	Proprietorship	507 Broad 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.	2021-08-17	Daniel Paul Bowser	danshonda12@gmail.com	Reinbeck	Grundy	Iowa	David Paul Bowser	Mary Ellen Sue Bowser	Signed	(1) The employer does not elect the employers’ liability coverage.	Sinnott Agency	toms@sinnottagency.com	Insurance provider	Waterloo	Blackhawk	Iowa	David Paul Bowser	Mary Ellen Sue Bowser	Signed
1482	2023-02-24 13:57	Anonymous (not verified)	94.188.205.175	Vaughn Seeds, LLC	Limited Liability Company	5025 13th Ave, La Porte City, IA 50651	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.	2023-02-24	Brice Jacob Vaughn	brice.vaughn1@gmail.com	La Porte Citty	Benton	Iowa	Abby Jo Rolston	Jessica Lyn McCabe	Signed	(1) The employer does not elect the employers’ liability coverage.	Abby Rolston	arolston@hagerins.net	Insured	La Porte City	Black Hawk	Iowa	Jessica Lyn McCabe	Russell Britson	Signed
1713	2023-06-27 09:06	Anonymous (not verified)	94.188.205.175	Ray's Painters, LLC	Limited Liability Company	4120 Mount Alpine Street, Dubuque, IA 52001	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-15	Danny Sexton	dsexton766@gmail.com	Dubuque	Dubuque	Iowa	Donna Gotto	Brenda Lewis	Signed	(1) The employer does not elect the employers’ liability coverage.	Ray's Painters LLC	dsexton766@gmail.com	insured	Dubuque	Dubuque	Iowa	Donna Gotto	Brenda Lewis	Signed
2054	2024-02-23 10:33	Anonymous (not verified)	94.188.205.175	Overgrown Lawn Care & Clean-Up LLC	Limited Liability Company	860 Main St. Stanhope, Iowa 50246	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.	2024-02-23	Shawn David King	shawndavidking@yahoo.com	Stanhope	Hamilton	Iowa	Michael Roland King	Chrisella Ann King	Signed	(1) The employer does not elect the employers’ liability coverage.	Shawn David King	overgrownlawn@yahoo.com	Is Owner	Stanhope	Hamilton	Iowa	Michael Roland King	Chrisella Ann King	Signed
163	2020-05-20 11:58	Anonymous (not verified)	173.27.1.111	David	Proprietorship	4023 E 28th st 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.	2021-05-20	David Ortiz	jdiconstrucction@gmail.com	Des Moines	Polk County	Iowa	Erika Olague	Jieldh Ortiz-Olague	Signed	(1) The employer does not elect the employers’ liability coverage.	David Ortiz	jdiconstrucction@gmail.com	JDI Construction	Des Moines	Polk County	Iowa	Erika Olague	Jieldh Ortiz-Olague	Signed
1109	2022-05-16 19:02	Anonymous (not verified)	173.20.161.18	Juan Manuel Alvarez	Proprietorship	2011 1st 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.	2022-05-16	Juan m. Alvarez	nemen01@hotmail.com	Perry	IA	IA	Ashley lynch	Omar Alvarez	Signed	(1) The employer does not elect the employers’ liability coverage.	Juan m. Alvarez	nemen01@hotmail.com	Juan	Perry	IA	IA	Ashley lynch	Omar Alvarez	Signed
1122	2022-05-21 12:19	Anonymous (not verified)	173.24.108.210	Daly Building Service,LLc	Limited Liability Company	409 Dammann dr. Eldridge IA, 52748	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.	2022-05-21	Noah Daly	Noahdalyubs@gmail.com	Eldridge	Scott County	Iowa	Holly Roberts	Corinna Daly	Signed	(1) The employer does not elect the employers’ liability coverage.	Derick Perry	biglakellc@outlook.com	Liability policy agent	Eldridge	Scott county	Iowa	Holly roberts	Corinna Daly	Signed
45	2020-01-28 16:13	Anonymous (not verified)	173.18.3.76	Delic Marble and Tile LLC	Limited Liability Company	24 Ellefson Dr PO Box 413 DeSoto, IA 50069	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-31	Adin Delic	delicgraniteandtile@gmail.com	Adel	Dallas	Iowa	Angela Kinsey	Taylor Benshoof	Signed	(1) The employer does not elect the employers’ liability coverage.	Lutfija Delic	delicgraniteandtile@gmail.com	LLC Member	Adel	Dallas	Iowa	Angela Kinsey	Taylor Benshoof	Signed
46	2020-01-28 16:32	Anonymous (not verified)	173.18.3.76	Delic Marble and Tile LLC	Limited Liability Company	24 Ellefson Dr PO Box 413 DeSoto, IA 50069	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2020-01-27	Lutfija Delic	delicgraniteandtile@gmail.com	Adel	Dallas	Iowa	Angela Kinsey	Taylor Benshoof	Signed	(1) The employer does not elect the employers’ liability coverage.	Adin Delic	delicgraniteandtile@gmail.com	LLC Member	Adel	Dallas	Iowa	Angela Kinsey	Taylor Benshoof	Signed
47	2020-01-28 16:35	Anonymous (not verified)	173.18.3.76	Delic Marble and Tile LLC	Limited Liability Company	24 Ellefson Dr PO Box 413 DeSoto, IA 50069	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-27	Sabahudin Delic	delicgraniteandtile@gmail.com	Adel	Dallas	Iowa	Angela Kinsey	Taylor Benshoof	Signed	(1) The employer does not elect the employers’ liability coverage.	Adin Delic	delicgraniteandtile@gmail.com	LLC Member	Adel	Dallas	Iowa	Angela Kinsey	Taylor Benshoof	Signed
126	2020-04-21 21:19	Anonymous (not verified)	69.76.135.87	Merge Midwest Engineering, LLC	Limited Liability Company	2668 W. Catalpa 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.	2020-04-21	Mark Daniel Stuempel	mstuempel@mergemidwest.com	Kansas City	Wyandotte	KANSAS	Anna Langer	Donna Stuempel	Signed	(1) The employer does not elect the employers’ liability coverage.	Janelle Clayton	jclayton@mergemidwest.com	LLC Member	Olathe	Johnson	KS	Anna Langer	Donna Stuempel	Signed
191	2020-06-23 16:09	Anonymous (not verified)	173.18.3.76	Look At You LLC	Limited Liability Company	5545 Mills Civic Pkwy Ste 100 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.	2020-06-23	Amber Keppler	keppler_ark@outlook.com	Des Moines	Polk	IA	Angela Kinsey	Jon Stetzel	Signed	(1) The employer does not elect the employers’ liability coverage.	Amber Keppler	keppler_ark@outlook.com	LLC Member	Des Moines	Polk	IA	Angela Kinsey	Jon Stetzel	Signed
193	2020-06-24 11:13	Anonymous (not verified)	173.28.196.82	Gray Nation LLC DBA Gray Goat Tattoo	Limited Liability Company	116 N 1st Street West Branch, Iowa 52358-9663	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.	2020-06-24	Elizabeth Gray	beth.gray516@gmail.com	West Branch	Cedar	Iowa	Luis Ordenana	Don Naugthon	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Elizabeth Gray	beth.gray516@gmail.com	LLC Member	West Branch	Cedar	Iowa	Luis Ordenana	Don Naughton	Signed
546	2021-06-22 15:41	Anonymous (not verified)	208.95.1.97	BAJ FLOORING, LLC	Limited Liability Company	31533 CASTLE COURT, DYERSVILLE, IA. 52040	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.	2021-06-11	BRIAN JACQUE	jacquebrian18@gmail.com	DYERSVIILLE	DUBUQUE	IOWA	STEPHEN J. SCHLUETER	PAULA FITZGERALD	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	BRIAN JACQUE	jacquebrian18@gmail.com	LLC MEMBER	DYSERSVILLE	DUBUQUE	IOWA	STEPHEN J. SCHLUETER	PAULA FITZGERALD	Signed
633	2021-09-08 10:35	Anonymous (not verified)	208.95.1.97	BAJ Flooring, LLC	Limited Liability Company	31533 Castle Ct. Dyersville, IA. 52040-7600	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.	2021-09-08	Brian Jacque	JacqueBrian18@gmail.com	Dyersville	Dubuque	Iowa	Stephen J. Schluter	Paula Fitzgerald	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Brian A. Jacque	JacqueBrian18@gmail.com	LLC MEMBER	Dyersville	DUBUQUE	IOWA	Stephen J. Schlueter	Stephen J. Schlueter	Signed
944	2022-03-03 13:54	Anonymous (not verified)	192.95.125.191	B&R Enterprises LLC	Limited Liability Company	2850 73rd St., Newhall, IA 52315	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.	2022-02-17	Bradley Rick	ashlyn@3riversins.net	Newhall	Benton	Iowa	Ashlyn Christianson	Angie McFarland	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Ronald Jarrett	brsirenguys@gmail.com	LLC Member	Newhall	Benton	Iowa	Ashlyn Christianson	Angie McFarland	Signed
1651	2023-05-16 22:18	Anonymous (not verified)	94.188.205.175	Corridor Cleaning Services, LLC	Limited Liability Company	4621 Orchard Dr NW, Cedar Rapids, Iowa, 52405	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-11	Andrew Kleineck	andrew@corridorcleaning.net	Cedar Rapids	Linn	Iowa	Cole Smith	Suzanne Brue	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Kleineck	andrew@corridorcleaning.net	LLC Member	Cedar Rapids	Linn	Iowa	Cole Smith	Suzanne Brue	Signed
2144	2024-04-10 14:23	Anonymous (not verified)	94.188.205.176	Heaven Sent PC LLC	Limited Liability Company	604 Allamakee 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.	2024-04-10	Justin PIggott	heavensentpetcremation@gmail.com	Waukon	Allamakaee	IA	Jane M Regan	Nancy Bechtel	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Piggott	heavensentpetcremation@gmail.com	LLC Member	Waukon	Allamakee	IA	Jane M Regan	Nancy Bechtel	Signed
963	2022-03-10 10:51	Anonymous (not verified)	173.29.157.192	Thompson Servcies LLC	Limited Liability Company	21105 N Brady 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.	2022-03-10	Daniel M Konrardy	dkonrardy64@yahoo.com	Davenport	Scott	Iowa	David Konrardy	Cheryl Thompson	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel M Konrardy	dkonrardy64@yahoo.com	LLC member/partner	Davenport	Scott	Iowa	David Konrardy	Cheryl Thompson	Signed
1678	2023-06-06 08:13	Anonymous (not verified)	94.188.205.168	Castor Construction	Limited Liability Company	1515 Avenue O Fort Dodge, Iowa 50501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-06	Kit Hovey	hoveykit@gmail.com	FORT DODGE	Webster	United States	Alexis Malm	Kit Hovey	Signed	(1) The employer does not elect the employers’ liability coverage.	Noah Carspecken	noah@castorconstructionco.com	Management	FORT DODGE	Webster	United States	Alexis Malm	Kit Hovey	Signed
813	2021-12-27 10:18	Anonymous (not verified)	172.58.84.252	LLC	Partnership	866 40th Ave Bettendorf, 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.	2021-12-23	Kimberly Anne Liggitt	kliggitt25@gmail.com	Rock Island	IL	United States	Suzanne Jeanette Liggitt	Christie Marie Liggitt	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody Dunbar	codydunbar@leaffilter.com	Manager	866 40th Ave Bettendorf ia 52722	Scott County	IA	Jordan nisiewicz	Cody Dunbar	Signed
817	2021-12-30 12:58	Anonymous (not verified)	50.80.80.37	Leaf Filter	Limited Liability Company	1595 Georgetown Road Hudson, OH 44236	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.	2021-12-30	Kenneth Van Hook	kennyvanhook1976@gmail.com	Port Byron	Rock Island	IL	Sharon Van Hook	Judy Hoffman	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody Dunbar	cdunbar@leaffilter.com	Manager	Bettendorf	Scott County	IA	Cody Dunbar	Jordan Nisiewicz	Signed
820	2022-01-03 10:41	Anonymous (not verified)	174.195.193.112	Wolverine Construction LLC	Limited Liability Company	467 s 84th 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.	2022-01-03	steffan sheehey	steffanrobert@gmail.com	West Des Moines	Dallas	IA	Christopher Sheehey	Taylor Lyman	Signed	(1) The employer does not elect the employers’ liability coverage.	steffan sheehey	steffanrobert@gmail.com	Manager	West Des Moines	Dallas	IA	Christopher Sheehey	Marcus Hatcher	Signed
896	2022-02-04 11:58	Anonymous (not verified)	198.167.180.146	Northtowne Market Lot 7, LLC	Limited Liability Company	1005 Blairs Ferry Road NE, Cedar Rapids, IA 52404	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	Benjamin Wickum	bwickum@collinscu.org	CEDAR RAPIDS	Linn	Iowa	Jody Comried	Pat Milke	Signed	(1) The employer does not elect the employers’ liability coverage.	Benjamin Wickum	bwickum@collinscu.org	Manager	Cedar Rapids	Linn	Iowa	Jody Comried	Pat Milke	Signed
1467	2023-02-17 16:14	Anonymous (not verified)	94.188.205.169	H & C Construction	Limited Liability Company	708 Vine Street Lucas IA 50151	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.	2023-02-17	Colton Charles Clarke	ccclarke95@gmail.com	Truro	IA	United States	Hailey Sullivan	Shelby Comer	Signed	(1) The employer does not elect the employers’ liability coverage.	H & C Construction	ccclarke95@gmail.com	Manager	Truro	IA	United States	Hailey Sullivan	Shelby Comer	Signed
1508	2023-03-09 10:34	Anonymous (not verified)	94.188.205.176	H & C Construction	Limited Liability Company	708 Vine Street Lucas IA 50151	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.	2023-03-09	Colton Charles Clarke	ccclarke95@gmail.com	Truro	IA	United States	Hailey A Sullivan	Shelby Comer	Signed	(1) The employer does not elect the employers’ liability coverage.	Colton Charles Clarke	ccclarke95@gmail.com	Manager	Truro	IA	United States	Hailey A Sullivan	Shelby Comer	Signed
1719	2023-07-01 21:34	Anonymous (not verified)	94.188.207.223	Granite & More	Limited Liability Company	4730 Tremont ave Davenport Iowa 52807	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.	2023-07-01	Hong Le	granite732@yahoo.com	Davenport	Scott	Iowa	Jin Chen	Betty Song	Signed	(1) The employer does not elect the employers’ liability coverage.	Jin Chen	clteam563@gmail.com	Manager	Bettendorf	Scott	Iowa	Jin Chen	Betty Song	Signed
1758	2023-07-20 16:37	Anonymous (not verified)	94.188.205.174	Nailed It Remodeling Services LLC	Limited Liability Company	1520 Burnett Ave Ames, IA 50010	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-20	Kaylyn Christianson	kaylynchristianson@gmail.com	Ames	Story	Iowa	Jon Buller	Terry Miles	Signed	(1) The employer does not elect the employers’ liability coverage.	Kaylyn Christianson	KaylynChristianson@gmail.com	Manager	Ames	Story	Iowa	Jon Buller	Terry Miles	Signed
1868	2023-10-16 12:36	Anonymous (not verified)	94.188.205.177	North Bay Dock Service, LLC	Limited Liability Company	PO Box 374, 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.	2023-10-16	Teresa A. JOhnson	NBDSLLC@gmail.com	Spirit Lake	Dickinson	Iowa	Michael Chozen	April Bosma	Signed	(1) The employer does not elect the employers’ liability coverage.	Teresa Johnson	NBDSLLC@gmail.com	Manager	Spirit Lake	Dickinson	Iowa	Michael Chozen	April Bosma	Signed

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