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:
2149	2024-04-15 11:20	Anonymous (not verified)	94.188.207.224	Grady Yeggy	Proprietorship	211 3rd St. Riverside, IA 52327	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-11	Grady S Yeggy	kellylanz1967@gmail.com	Riverside	IA	United States	Amanda Yeggy	Leah Evans	Signed	(1) The employer does not elect the employers’ liability coverage.	Grady S Yeggy	kellylanz1967@gmail.com	Self	Riverside	IA	United States	Amanda Yeggy	Leah Yeggy	Signed
2207	2024-05-07 09:44	Anonymous (not verified)	94.188.207.226	Rodrimart brothers corp	Limited Liability Company	958 8th ave nw Altoona 50009	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-07	Enrique Rodriguez	carluto_1983@hotmail.com	Altoona	Polk	Iowa	Adan boge	Lonce wester	Signed	(1) The employer does not elect the employers’ liability coverage.	Enrique Rodriguez	carluto_1983@hotmail.com	President	Altoona	Polk	Iowa	Adan boge	Leans wester	Signed
1764	2023-07-27 09:56	Anonymous (not verified)	94.188.207.224	Tracy Spray	Proprietorship	479 old lincoln hwy Mechanicsville Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-27	Tracy spray	tspray9@hotmail.com	Mechanicsville	Cedar	Iowa	Dillon Williams	Leighton Raplinger	Signed	(1) The employer does not elect the employers’ liability coverage.	Tracy Spray	tspray9@hotmail.com	Owner	Mechanicsville	Cedar	Iowa	Dillon Williams	Leighton Raplinger	Signed
1131	2022-05-26 15:31	Anonymous (not verified)	173.215.7.226	Leon's Construction	Limited Liability Company	524 CHURCH CIRCLE Jesup Ia. 50648	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.	2022-05-26	Leon Francis Delagardelle	ldel1191961@hotmail.com	JESUP	Iowa	Iowa	Leon Francis Delagardelle	Leon Francis Delagardelle	Signed	(1) The employer does not elect the employers’ liability coverage.	Leon Francis Delagardelle	ldel1191961@hotmail.com	self	JESUP	Iowa	Iowa	Leon Francis Delagardelle	Leon Francis Delagardelle	Signed
1518	2023-03-15 10:53	Anonymous (not verified)	94.188.205.176	Leon's Construction	Limited Liability Company	524 CHURCH 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.	2023-03-15	Leon Francis Delagardelle	ldel1191961@hotmail.com	JESUP	Iowa	United States	Leon Francis Delagardelle	Leon Francis Delagardelle	Signed	(1) The employer does not elect the employers’ liability coverage.	Leon Francis Delagardelle	ldel1191961@hotmail.com	self	JESUP	Iowa	United States	Leon Francis Delagardelle	Leon Francis Delagardelle	Signed
345	2020-12-29 09:20	Anonymous (not verified)	173.18.16.129	Eben-Ezer Concrete Services	Proprietorship	1283 dixon st. Des Moines IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-12-29	Saul Artero	Artro50313@yahoo.com	Des Moines	Polk	Iowa	Jen Lambert	Lesa Reeves	Signed	(1) The employer does not elect the employers’ liability coverage.	Saul Artero	Artro50313@yahoo.com	owner	des moines	Polk	Iowa	Jen Lambert	Lesa Reeves	Signed
355	2021-01-11 16:29	Anonymous (not verified)	173.18.16.129	Neil Bitting Construction	Proprietorship	2607 E 39th ct Des Moines Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-11	Neil Bitting	bittingneil@live.com	des Moines	polk	Iowa	Jen Lambert	Lesa Reeves	Signed	(1) The employer does not elect the employers’ liability coverage.	Neil Bitting	bittingneil@live.com	owner	des moines	polk	Iowa	Jen Lambert	Lesa Reeves	Signed
668	2021-10-12 16:11	Anonymous (not verified)	173.18.22.217	Mo's Cleaning LLC	Limited Liability Company	1412 E 23rd 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.	2021-10-12	Melissa Jones	commcleanwithme123@gmail.com	Des Moines	Polk	IA	Kelly Coluzzi	Lesa Reeves	Signed	(1) The employer does not elect the employers’ liability coverage.	Melissa Jones	commcleanwithme123@gmail.com	Owner	Des Moines	Polk	IA	Kelly Coluzzi	Lesa Reeves	Signed
1484	2023-02-25 16:42	Anonymous (not verified)	94.188.205.177	Carpenter wood shed/ rays longging	Limited Liability Company	1631 230th 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.	2023-02-27	Raymond Carpenter	corinnafrymoyer@gmail.com	tipton	Cedar	Iowa	corinna frymoyer	Levi carpenter	Signed	(1) The employer does not elect the employers’ liability coverage.	Raymond Carpenter	corinnafrymoyer@gmail.com	Self	Tipton	Cedar	Iowa	Corinna frymoyer	Levi carpenter	Signed
672	2021-10-13 16:05	Anonymous (not verified)	75.162.218.218	Arturos Interiors LLC	Limited Liability Company	3305 se 22nd apt 15 Des Moines IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-29	Arturo mejia	arturomcruz20@hotmail.com	Des Moines	polk	IA	yolanda mendoza	liliana sanchez	Signed	(1) The employer does not elect the employers’ liability coverage.	Arturo Mejia	arturomcruz20@hotmail.com	member	Des Moines	polk	IA	Yolanda Mendoza	lialiana sanchez	Signed
1553	2023-04-04 14:52	Anonymous (not verified)	94.188.205.177	TOPSOIL OUTDOOR SERVICES	Limited Liability Company	4919 SCHUBERT 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.	2023-04-04	LIBAN	topsoiloutdoor@gmail.com	AMES	IA	United States	Liban Wetzberger	Liban Wertzberger	Signed	(1) The employer does not elect the employers’ liability coverage.	Liban Wertzberger	topsoiloutdoor@gmail.com	Owner	AMES	IA	United States	Liban Wertzberger	Liban Wertzberger	Signed
588	2021-07-27 19:59	Anonymous (not verified)	75.162.226.22	Andres Martinez	Limited Liability Company	3903 SW 3rd St. Des Moines, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-27	Andres Martinez	and.am12am@gmail.com	Des Moines	Polk	Iowa	Carla Martinez	Librado Martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Andres Martinez	and.am12am@gmail.com	Employer	Des Moines	Polk	Iowa	Carla Martinez	Librado Martinez	Signed
1213	2022-07-19 14:00	Anonymous (not verified)	198.14.220.143	VLG Build & Remodle LLC	Limited Liability Partnership	45547 State HWY 14 Chariton, IA 50049	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	Vladimir Golosinskiy	VLGCONSTRUCTION@YAHOO.COM	Chariton	IA	United States	Vladimir Golosinskiy	Vladimir Golosinskiy	Signed	(1) The employer does not elect the employers’ liability coverage.	LILIA GOLOSINSKIY	VLGCONSTRUCTION@YAHOO.COM	Wife	CHARITON	Iowa	United States	LILIA GOLOSINSKIY	LILIA GOLOSINSKIY	Signed
554	2021-07-01 15:54	Anonymous (not verified)	75.162.212.130	Avila Gutters Inc	Proprietorship	5901 sw 5th st Des Moines IA 50315	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.	2021-06-24	Enrique Avila	enrique86avila@gmail.com	Des moines	polk	iowa	Yolanda Mendoza	Lilliana Sanchez	Signed	(1) The employer does not elect the employers’ liability coverage.	Enrique Avila	enrique86Avila@gmail.com	owner	des moines	polk	iowa	yolanda mendoza	liliana sanchez	Signed
620	2021-08-26 16:26	Anonymous (not verified)	75.162.146.246	Daniel Meza Reyes	Proprietorship	1640 E Army Post RD Des Moines IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-23	Daniel Meza Reyes	danielmr9247@gmail.com	Des Moines	polk	IA	Yolanda Mendoza	Liliana Sanchez	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Meza Reyes	danielmr9247@gmail.com	self	Des Moines	polk	IA	Yolanda Mendoza	Liliana Sanchez	Signed
675	2021-10-15 11:22	Anonymous (not verified)	75.162.156.37	MCG FLOORING, LLC	Limited Liability Company	2115 CARPENTER AVE DES MOINES IA 50311	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-15	GABRIELA GOMEZ	MCGFLOORINGLLC@GMAIL.COM	DES MOINES	USA	IA	YOLANDA MENDOZA	LILIANA SANCHEZ GUTIERREZ	Signed	(1) The employer does not elect the employers’ liability coverage.	MCG FLOORING, LLC	MCGFLOORINGLLC@GMAIL.CON	OWNER	DES MOINES	USA	IA	YOLANDA MENDOZA	LILIANA SANCHEZ GUTIERREZ	Signed
676	2021-10-15 11:29	Anonymous (not verified)	75.162.156.37	MCG FLOORING, LLC	Limited Liability Company	2115 CARPENTER AVE DES MOINES, IA 50311	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-10-15	MANUEL CONTRERAS BERNAL	MCGFLOORINGLLC@GMAIL.COM	DES MOINES	USA	IA	YOLANDA MENDOZA	LILIANA SANCHEZ GUTIERREZ	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	MCG FLOORING, LLC	MCGFLOORINGLLC@GMAIL.CON	OWNER	DES MOINES	USA	IA	YOLANDA MENDOZA	LILIANA SANCHEZ GUTIERREZ	Signed
747	2021-11-12 15:08	Anonymous (not verified)	75.162.157.80	Unique Hardwood Floors, LLC	Limited Liability Company	1202 Army Post Rd. des Moines, Iowa 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-12	Jose A Dominguez Lopez	uniquefloorsdmi@gmail.com	Des Moines	USA	Iowa	Elizabeth Dominguez	Liliana Sanchez Gutierrez	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose A Dominguez Lopez	uniquefloorsdmi@gmail.com	Owner	Des Moines	USA	Iowa	Elizabeth Dominguez	Liliana Sanchez Gutierrez	Signed
1099	2022-05-13 12:17	Anonymous (not verified)	75.162.66.90	EMPIRE CONTRACTORS, LLC	Limited Liability Company	8415 FRANKLIN AVE APT 18 CLIVE, IOWA 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.	2022-05-13	RENE ALEXANDER VELASCO	velasco.alexander@yahoo.com	Des Moines	USA	Iowa	Yolanda Mendoza	Liliana Sanchez Gutierrez	Signed	(1) The employer does not elect the employers’ liability coverage.	RENE ALEXANDER VELASCO	velasco.alexander@yahoo.com	OWNER	DES MOINES	USA	IOWA	YOLANDA MENDOZA	LILIANA SANCHEZ GUTIERREZ	Signed
1102	2022-05-13 13:13	Anonymous (not verified)	75.162.173.244	EMPIRE CONTRACTORS, INC	Proprietorship	8415 FRANKLIN AVE APT 18 CLIVE, IOWA 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.	2022-05-13	RENE ALEXANDER VELASCO	velasco.alexander@yahoo.com	DES MOINES	USA	IOWA	YOLANDA MENDOZA	LILIANA SANCHEZ GUTIERREZ	Signed	(1) The employer does not elect the employers’ liability coverage.	RENE ALEXANDER VELASCO	velasco.alexander@yahoo.com	COMPANY OWNER	DES MOINES	USA	IOWA	YOLANDA MENDOZA	LILIANA SANCHEZ GUTIERREZ	Signed
788	2021-12-14 09:36	Anonymous (not verified)	162.250.36.34	Sylvester Enterprises, LLC	Limited Liability Company	4800 Sylvester Rd. Webb, Ia. 51366	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.	2021-12-14	Tim Christian Sylvester	isusly89@gmail.com	Webb	Clay	Iowa	Dennis Dwain Somers	LInda Elayne Somers	Signed	(1) The employer does not elect the employers’ liability coverage.	Tim Christian Sylvester	slyenterprisesllc20@gmail.com	Owner	Webb	Clay	Iowa	Dennis Dwain Somers	Linda Elayne Somers	Signed
789	2021-12-14 09:39	Anonymous (not verified)	162.250.36.34	Sylvester Enterprises, LLC	Limited Liability Company	4800 Sylvester Rd. Webb, Iowa 51366	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.	2021-12-14	Christian Grant Sylvester	slyfarms97@gmail.com	Webb	Clay	iowa	Dennis Dwain Somers	LInda Elayne Somers	Signed	(1) The employer does not elect the employers’ liability coverage.	Tim Christian Sylvester	slyenterprisesllc20@gmail.com	Owner	Webb	Clay	Iowa	Dennis Dwain Somers	Linda Elayne Somers	Signed
1532	2023-03-24 18:05	Anonymous (not verified)	94.188.205.174	Crafty Dome LLC	Limited Liability Company	3524 Stonebridge Rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-24	Susan Bernau	craftydome@yahoo.com	West Des Moines	Polk	Iowa	George Cummins	Linda Green	Signed	(1) The employer does not elect the employers’ liability coverage.	Susan Bernau	craftydome@yahoo.com	owner	3524 Stonebridge Rd	Polk	Iowa	George Cummins	Linda Green	Signed
540	2021-06-08 21:40	Anonymous (not verified)	50.83.39.243	Brightland Appraisal Group	Limited Liability Company	1348 Rolling Glen Dr. Marion IA 52302	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.	2021-06-08	Eric Lamp	eric.lamp@brightlandappraisal.com	Marion	Linn	Iowa	Sarah Lamp	Linda Lamp	Signed	(1) The employer does not elect the employers’ liability coverage.	Eric Allen Lamp	eric.lamp@brightlandappraisal.com	Self	Marion	Linn	Iowa	Sarah Lamp	Linda Lamp	Signed
162	2020-05-19 15:03	Anonymous (not verified)	67.212.114.80	Collum Plumbing, LLC	Limited Liability Company	610 West 20th Street, Cedar Falls, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-19	Stephen Collum	collumplumbing@cfu.net	Cedar Falls	Iowa	United States	Mike Thode	Linda Thode	Signed	(1) The employer does not elect the employers’ liability coverage.	Stephen Collum	collumplumbing@cfu.net	Member of LLC	Cedar Falls	Black Hawk	Iowa	Mike Thode	Linda Thode	Signed
1657	2023-05-22 14:31	Anonymous (not verified)	94.188.207.224	Collum Plumbing, LLC	Limited Liability Company	610 West 20th, 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.	2023-05-22	Stephen Collum	collumplumbing@cfu.net	Cedar Falls	Iowa	United States	Mike Thode	Linda Thode	Signed	(1) The employer does not elect the employers’ liability coverage.	Stephen Collum	collumplumbing@cfu.net	Owner/Member of LLC	Cedar Falls	Black Hawk	Iowa	Mike Thode	Linda Thode	Signed
1506	2023-03-08 15:12	Anonymous (not verified)	94.188.207.226	Heritage Towing LLC	Limited Liability Company	404 Sherman Ave. Ackley Iowa 50601	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.	2023-03-08	Jeff Brass	heritagemotors17@yahoo.com	Ackley	Hardin	Iowa	Joellen Reynolds	Linzie Morris	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeff Brass	hertiagemotors17@yahoo.com	Member of LLC	Ackley	Hardin	Iowa	JoEllen Reynolds	Linzie Morris	Signed
2145	2024-04-11 12:27	Anonymous (not verified)	94.188.205.177	Grinnell Web Services LLC	Limited Liability Company	1902 Spring St, Grinnell IA 50112	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-11	Richard Ethington	RDE326@rrmse.com	Grinnell	Poweshiek	Iowa	Lori Stratton	Lisa Folkmann	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard Ethington	rde326@rrmse.com	self	Grinnell	poweshiek	iowa	lori stratton	lisa folkmann	Signed
586	2021-07-26 08:37	Anonymous (not verified)	71.7.62.131	Jeffrey Knoot	Proprietorship	1251 Illinois Dr. Knoxville IA, 50138-8862	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-26	Jeffrey Jon Knoot	opsisdental@gmail.com	Knoxville	Marion	Iowa	Sharon Kay Spriggs	Lisa Michelle Dudley	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeffrey Jon Knoot	opsisdental@gmail.com	self	Knoxville	Marion	Iowa	Sharon Kay Spriggs	Lisa Michelle Dudley	Signed
1400	2022-12-22 10:02	Anonymous (not verified)	166.196.110.105	It's a Breeze Cleaning Service	Proprietorship	760 W 8th Ave Marion, IA 52302	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.	2022-12-22	Breonna Nelson	breanderson82@yahoo.com	Marion	Linn	Iowa	Tyler Nelson	Lisa Nelson	Signed	(1) The employer does not elect the employers’ liability coverage.	Breonna Nelson	Breanderson82@yahoo.com	Self	Marion	Linn	IA	Tyler Nelson	Lisa Nelson	Signed
1159	2022-06-17 10:58	Anonymous (not verified)	174.235.208.232	Vertex Construction Services	Limited Liability Company	1620 E Diehl Ave, Des Moines, IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-17	William Dombrowski	wdombrowski629@gmail.com	Des moines	Polk	Iowa	Clark Newbury	Lisa Rodriguez	Signed	(1) The employer does not elect the employers’ liability coverage.	William Dombrowski	wdombrowski629@gmail.com	Owmer	Des moines	Polk	Iowa	Clark Newbury	Lisa Rodriguez	Signed
358	2021-01-12 11:35	Anonymous (not verified)	173.29.116.114	Des Moines Restorations LLC	Limited Liability Company	1701 Pennsylvania Avenue, Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-12	Christopher Rogers	chris@desmoinesrestorations.com	Davenport	Scott	IA	Lea Luquire	Lisa Rubio	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher Rogers	chris@desmoinesrestorations.com	Owner / Employer	Davenport	Scott	IA	Lea Luquire	Lisa Rubio	Signed
359	2021-01-12 11:37	Anonymous (not verified)	173.29.116.114	Quad City Restorations	Limited Liability Company	1225 E River Drive, Suite 320, Davenport, IA 52803	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-12	Christopher Rogers	chris@quadcityrestorations.com	DAVENPORT	Scott	IA	Lea Luquire	Lisa Rubio	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher Rogers	chris@quadcityrestorations.com	Owner / Employer	DAVENPORT	Scott	IA	Lea Luquire	Lisa Rubio	Signed
2103	2024-03-18 12:33	Anonymous (not verified)	94.188.205.177	Scornos 1973 Inc	Proprietorship	8561 hickman rd urbandale iowa 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-18	Liana Fatino	lfatino@yahoo.com	des moines	POLK	IOWA	GARY FATINO	LISA VACCO	Signed	(1) The employer does not elect the employers’ liability coverage.	GARY FATINO	lfatino@yahoo.com	husband	des moines	polk	iowa	Gary Fatino	Lisa Vacco	Signed
2104	2024-03-18 12:36	Anonymous (not verified)	94.188.205.167	Scornoos 1973 INC	Proprietorship	8561 hickman rd urbandale iowa 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-18	Gary Fatino	lfatino@yahoo.com	des moines	Polk	iowa	Liana Fatino	LISA VACCO	Signed	(1) The employer does not elect the employers’ liability coverage.	Liana Fatino	lfatino@yahoo.com	wife	des moines	polk	iowa	Liana Fatino	Lisa vacco	Signed
2105	2024-03-18 12:45	Anonymous (not verified)	94.188.205.169	Scornos Altoona LLC	Proprietorship	2437 adventureland dr altoona iowaa 50009	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-18	Liana Fatino	lfatino@yahoo.com	des moines	POLK	IOWA	GARY FATINO	LISA VACCO	Signed	(1) The employer does not elect the employers’ liability coverage.	GARY FATINO	lfatino@yahoo.com	husband	des moines	polk	iowa	Gary Fatino	Lisa Vacco	Signed
2106	2024-03-18 12:47	Anonymous (not verified)	94.188.205.167	Scornos Altoona LLC	Proprietorship	2437 adventureland dr altoona iowaa 50009	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-18	Gary Fatino	lfatino@yahoo.com	des moines	POLK	IOWA	Liana Fatino	LISA VACCO	Signed	(1) The employer does not elect the employers’ liability coverage.	Liana Fatino	lfatino@yahoo.com	wife	des moines	polk	iowa	Liana Fatino	Lisa Vacco	Signed
1221	2022-07-21 13:40	Anonymous (not verified)	129.222.3.107	Barkers Handyman Express	Proprietorship	120 S Mill St Gilman, IA 50106	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.	2022-07-22	Devin Levi Barker	devinbarker91@gmail.com	Gilman	Marshall	Iowa	Emily Anne Barker	Lloyd Owen Barker Jr.	Signed	(1) The employer does not elect the employers’ liability coverage.	Devin Levi Barker	devinbarker91@gmail.com	Owner	Gilman	Marshall	IA	Emily Anne Barker	Lloyd Owen Barker Jr.	Signed
1813	2023-08-22 15:44	Anonymous (not verified)	94.188.205.176	Hart and Company	Limited Liability Company	PO Box 757 Indianola IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-22	Andrew Hart	hartinnovate@gmail.com	Ackworth	Warren	Iowa	John M Keller	Logan David	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Hart	hartinnovate@gmail.com	Self	Ackworth	Warren	Iowa	John M Keller	Logan David	Signed
799	2021-12-15 11:48	Anonymous (not verified)	74.84.79.78	Juan Martinez Slazar	Proprietorship	7085 Bloomfield Rd. Lot # 38	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-11-01	Juan A. Martinez Salazar	juan50320@gmail.com	Des Moines	Polk	Iowa	Steve Young	Logan Giudicessi	Signed	(1) The employer does not elect the employers’ liability coverage.	Juan A. Martinez Salazar	juan50320@gmail.com	Owner	Des Moines	Polk	Iowa	Steve Young	Logan Giudicessi	Signed
1389	2022-12-11 12:36	Anonymous (not verified)	24.149.1.5	Project Fix It LLC	Limited Liability Company	1303 Washington Street Cedar Falls 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.	2022-12-12	Adam L Reiter	adam.reiter@projectfixit.net	Cedar Falls	IA	United States	Jennifer Reiter	Logan Reiter	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Project Fix It	adam.reiter@projectfixit.net	Owner	Cedar Falls	IA	United States	Jennifer Reiter	Logan Reiter	Signed
950	2022-03-04 19:58	Anonymous (not verified)	173.26.94.212	JRH Services	Limited Liability Company	525 Third 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.	2022-03-04	Joshua Blakeslee	jrhservicesiowa@outlook.com	Evansdale	Blackhawk	IA	Nicole Blakeslee	Lois Riggleman	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua Blakeslee	jrhservicesiowa@outlook.com	Owner	Evansdale	Blackhawk	IA	Nicole Blakeslee	Lois Riggleman	Signed
55	2020-02-07 15:14	Anonymous (not verified)	204.153.176.73	J*M Fuels, LLC	Limited Liability Company	600 W Bremer Avenue, Waverly IA 50677	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-07	Matt Johnson	mattjohnson7555@gmail.com	Jackson TWP	Butler	Iowa	Ty Burke	Lori Frerichs	Signed	(1) The employer does not elect the employers’ liability coverage.	Tylor Burke	tburke@acceladvantage.com	Agent	Waverly	IA	United States	Tony Pollastrini	Lori Frerichs	Signed
56	2020-02-07 15:17	Anonymous (not verified)	204.153.176.73	J*M Fuels, LLC	Limited Liability Company	600 W Bremer Avenue, Waverly IA 50677	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-07	Jim Johnson	mattjohnson7555@gmail.com	Jackson TWP	Butler	Iowa	Ty Burke	Lori Frerichs	Signed	(1) The employer does not elect the employers’ liability coverage.	Ty Burke	tburke@acceladvantage.com	Agent	Waverly	IA	United States	Tony Pollastrini	Lori Frerichs	Signed
1481	2023-02-24 12:45	Anonymous (not verified)	94.188.207.223	Molly Onken	Limited Liability Company	52480 HWY 210 Slater, IA. 50244	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	Molly S Onken	mollyaols@gmail.com	Slater	Story	Iowa	Pamela A Wilson	Lori Konzen	Signed	(1) The employer does not elect the employers’ liability coverage.	Molly S Onken	mollyaols@gmail.com	Owner	Slater	Story	Iowa	Pamela A Wilson	Lori Konzen	Signed
290	2020-10-23 15:13	Anonymous (not verified)	74.42.24.42	Gunter Trucking LLC	Limited Liability Company	704 River Ave N., Belmond, IA 50421	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-23	Michael James Gunter	mikegunter885@yahoo.com	Belmond	Wright	Iowa	Sondra Faye Godsell	Lori Lynn Studer	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael James Gunter	mikegunter885@yahoo.com	Owner	Belmond	Wright	Iowa	Sondra Faye Godsell	Lori Lynn Studer	Signed
522	2021-05-17 20:27	Anonymous (not verified)	50.81.4.25	Crew Cut Lawn Care	Limited Liability Company	7820 1st Ave NW Cedar Rapids, IA 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.	2021-05-17	Rupert McKendly Ellis	wideglide94@gmail.com	Cedar Rapids	Linn	Iowa	Adrian Pink	Lorraine Ellis	Signed	(1) The employer does not elect the employers’ liability coverage.	Rupert M Ellis	wideglide94@gmail.com	Owner	Cedar Rapids	Linn	IA	Adrian Pink	Lorraine	Signed
2160	2024-04-17 18:21	Anonymous (not verified)	94.188.207.226	QC Remodeling LLC	Limited Liability Company	421 West Broadway, Ste 302 Council Bluffs, IA 51503	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-17	Fernando Ibarra	ibarra_fernando@hotmail.com	Rock Island	Rock Island	Illinois	Paula Barria	Louis Valencia	Signed	(1) The employer does not elect the employers’ liability coverage.	Fernando Ibarra	ibarra_fernando@hotmail.com	Owner	Rock Island	Rock Island	Illinois	Paula Barria	Louis Valencia	Signed
1805	2023-08-17 10:00	Anonymous (not verified)	94.188.207.229	Polly Pattison Sewing LLC	Limited Liability Company	6917 New York 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.	2023-08-17	Polly Pattison	pollypattison@msn.com	Urbandale	Polk	IA	Lynn Niceswanger	Louise Anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Polly Pattison	pollypattison@msn.com	Same	Urbandale	Polk	Iowa	Lynn Niceswanger	Louise Anderson	Signed
106	2020-03-31 10:42	Anonymous (not verified)	209.152.77.101	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln ST., Ruthven, IA 51358	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.	2020-03-31	Bart Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Janice Henningsen	Louise Helmke	Signed	(1) The employer does not elect the employers’ liability coverage.	Bart Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Janice Henningsen	Louise Helmke	Signed

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