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:
140	2020-04-28 10:13	Anonymous (not verified)	74.84.101.138	Lutheran Cemetery Association	Proprietorship	410 S. Mechanic Street Decorah, IA 52101	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-21	John D Noel	chelsea.whalen@upperiowains.com	Decorah	Winneshiek	IA	Robin C Schultz	Bobbi Jo Berg	Signed	(1) The employer does not elect the employers’ liability coverage.	John D Noel	chelsea.whalen@upperiowains.com	President	Decorah	Winneshiek	IA	Robin C Schultz	Bobbi Jo Berg	Signed
141	2020-04-28 10:14	Anonymous (not verified)	74.84.101.138	Lutheran Cemetery Association	Proprietorship	410 S. Mechanic Street Decorah, IA 52101	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.	2020-03-02	Steven Matter	chelsea.whalen@upperiowains.com	Decorah	Winneshiek	IA	Bobbi Jo Berg	Robin C Schultz	Signed	(1) The employer does not elect the employers’ liability coverage.	Steven Matter	chelsea.whalen@upperiowains.com	Secretary	Decorah	Winneshiek	IA	BOBBI JO BERG	Robin C Schultz	Signed
142	2020-04-28 10:16	Anonymous (not verified)	74.84.101.138	Lutheran Cemetery Association	Proprietorship	410 S. Mechanic Street Decorah, IA 52101	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-18	Timothy A Stoddard	chelsea.whalen@upperiowains.com	Decorah	Winneshiek	IA	Robin C Schultz	Bobbi Jo Berg	Signed	(1) The employer does not elect the employers’ liability coverage.	Timothy A Stoddard	chelsea.whalen@upperiowains.com	Treasurer	Decorah	Winneshiek	IA	Robin C Schultz	Bobbi Jo Berg	Signed
145	2020-04-30 16:09	Anonymous (not verified)	173.191.206.253	Mark Knapp	Proprietorship	11244 Linden 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.	2020-04-30	Mark A Knapp	mlmlknapp@iowatelecom.net	Linden	Iowa	United States	Phil Hesseltine	Kathy Hesseltine	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Knapp	mlmlknapp@iowatelecom.net	self	Linden	Iowa	United States	Phil Hesseltine	Kathy Hesseltine	Signed
147	2020-05-02 09:07	Anonymous (not verified)	75.162.65.142	Tim Soy	Proprietorship	3506 Amherst 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.	2020-05-01	Timothy Soy	kingsoyboy@hotmail.com	Des Moines	Polk	Iowa	Aaron Page	Jeremy Lukehart	Signed	(1) The employer does not elect the employers’ liability coverage.	Timothy Soy	kingsoyboy@hotmail.com	Self	Des Moines	Polk	Iowa	Aaron page	Jeremy Lukehart	Signed
148	2020-05-04 15:49	Anonymous (not verified)	173.28.28.57	LaRae Randall dba Wild Soul Photo	Proprietorship	19019 O Avenue, Grundy Center, IA 50638	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.	2020-04-27	LaRae Randall	cmins_re@mchsi.com	Grundy Center	Grundy	IA	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	LaRae Randall	cmins_re@mchsi.com	Self	Grundy Center	Grundy	IA	Chad Campbell	Roxanne Kolder	Signed
149	2020-05-06 08:33	Anonymous (not verified)	66.188.136.150	Lacey Doyle	Proprietorship	210 Austin Ct. Apt 10 Epworth, IA 52045	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.	2020-05-05	Lacey Doyle	kschumacher@tricorinsurance.com	Epworth	Dubuque	IA	Russell Masartis	Rose Horstman	Signed	(1) The employer does not elect the employers’ liability coverage.	Lacey Doyle	kschumacher@tricorinsurance.com	Same	Epworth	Dubuque	IA	Russell Masartis	Rose Horstman	Signed
155	2020-05-12 17:03	Anonymous (not verified)	173.17.184.241	Shelly Whalen	Proprietorship	1625 Darby Dr Waterloo IA 50702	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-12	Shelly Whalen	swhalen90@hotmail.com	Waterloo	IA	United States	Taylor Whalen	Todd Gerleman	Signed	(1) The employer does not elect the employers’ liability coverage.	Shelly Whalen	swhalen90@hotmail.com	self employed	Waterloo	IA	United States	Taylor Whalen	Todd Gerleman	Signed
157	2020-05-14 15:11	Anonymous (not verified)	173.28.28.57	Brett Dix	Proprietorship	16696 245th Street, Aplington, IA 50604	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.	2020-04-30	Brett Dix	cmins_re@mchsi.com	Aplington	Butler	IA	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Brett Dix	cmins_re@mchsi.com	Self	Aplington	Butler	IA	Chad Campbell	Roxanne Kolder	Signed
159	2020-05-18 14:21	Anonymous (not verified)	173.28.28.57	Matthew Klahsen	Proprietorship	1103 Gray Street, Aplington IA 50604	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.	2020-05-12	Matthew Klahsen	cmins_re@mchsi.com	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Klahsen	cmins_re@mchsi.com	Self	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
160	2020-05-18 15:04	Anonymous (not verified)	173.28.28.57	Angela Scanlan	Proprietorship	26436 320th Street, Parkersburg IA 50665	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.	2020-04-28	Angela Scanlan	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Angela Scanlan	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
161	2020-05-19 11:31	Anonymous (not verified)	208.95.1.97	Paul McCoy DBA McCoy Contracting	Proprietorship	2806 Highway T47, Montour, Iowa 50173	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	Paul McCoy	paulrmccoy1969@gmail.com	Montour	Tama	Iowa	Mike Thede	Toni Chaska	Signed	(1) The employer does not elect the employers’ liability coverage.	Paul McCoy	paulrmccoy1969@gmail.com	Owner	Montour	Tama	Iowa	Mike Thede	Toni Chaska	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
164	2020-05-26 10:30	Anonymous (not verified)	166.182.80.35	T.W. Barton Restoration Service	Proprietorship	2704 Cass Avenue Mount Pleasant, Iowa 52641	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.	2020-05-26	Todd William Barton II	twbartonrestoration@yahoo.com	Mount Pleasant	Henry	Iowa	Olivia Grace Barton	Todd William Barton Sr.	Signed	(1) The employer does not elect the employers’ liability coverage.	Todd William Barton II	twbartonrestoration@yahoo.com	Self	Mount Pleasant	Henry	Iowa	Olivia Grace Barton	Todd William Barton Sr.	Signed
166	2020-05-27 11:48	Anonymous (not verified)	66.188.136.150	Kevin Kerstetter	Proprietorship	1080 E 12th St. 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.	2020-05-26	Kevin Kerstetter	kschumacher@tricorinsurance.com	Cuyahoga Falls	Summit County	OH	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	Kevin Kerstetter	kschumacher@tricorinsurance.com	Same	Cuyahoga Falls	Summit County	OH	Russell Masartis	Nancy Wortley	Signed
167	2020-05-27 11:51	Anonymous (not verified)	66.188.136.150	Dennis Heinlen	Proprietorship	3415 Upland Rd. Lowellville, OH	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.	2020-05-26	Dennis Heinlen	kschumacher@tricorinsurance.com	Lowellville	Mahoning	OH	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	Dennis Heinlen	kschumacher@tricorinsurance.com	Same	Lowellville	Mahoning	OH	Russell Masartis	Nancy Wortley	Signed
170	2020-06-01 13:31	Anonymous (not verified)	173.28.28.57	Rachel Poppens	Proprietorship	910 Parriott Street, Aplington IA 50604	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	Rachel Poppens	cmins_re@mchsi.com	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Rachel Poppens	cmins_re@mchsi.com	Self	Aplington	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
172	2020-06-02 15:56	Anonymous (not verified)	66.188.136.150	David Bull	Proprietorship	221 N Aarlocker 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.	2020-06-02	David Bull	kschumacher@tricorinsurance.com	Mount Hope	Grant	WI	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	David Bull	kschumacher@tricorinsurance.com	Same	Mount Hope	Grant	WI	Russell Masartis	Nancy Wortley	Signed
173	2020-06-04 11:22	Anonymous (not verified)	167.142.93.121	Chad Hauschild dba Chad Hauschild Logging	Proprietorship	23864 190th St, Farmersburg, IA 52047	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.	2020-06-04	Chad Hauschild	michael@giffordinsurance.net	Farmersburg	Clayton	Iowa	Angela Keppler	Kevin Lau	Signed	(1) The employer does not elect the employers’ liability coverage.	Chad Hauschild	michael@giffordinsurance.net	Self	Farmersburg	Clayton	Iowa	Angela Keppler	Kevin Lau	Signed
179	2020-06-09 11:22	Anonymous (not verified)	173.31.147.225	SAUL GUERARA MEZA	Proprietorship	26 WESTVIEW DRIVE APT 5 MILFORD IA 51351	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-21	SAUL GUERARA MEZA	ESMEJ2513@GMAIL.COM	MILFORD	DICKINSON	IOWA	ESMIRALDO JIMENEZ	TAMI KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	SAUL GUERARA MEZA	ESMEJ2513@GMAIL.COM	SELF	MILFORD	DICKINSON	IOWA	ESMIRALDO JIMENEZ	TAMI KLEIN	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
183	2020-06-12 08:23	Anonymous (not verified)	107.77.173.7	A&W Marble & Tile	Proprietorship	5624 Sw 5Th Pl	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.	2020-06-12	Wayne A Yergy	wyergy@gmail.com	Des Moines	IA	United States	Michael L Smith	Guy B Chaney	Signed	(1) The employer does not elect the employers’ liability coverage.	Wayne Yergy	wyergy@gmail.com	Self	Des Moines	IA	United States	Michael L Smith	Guy B Chaney	Signed
184	2020-06-12 10:38	Anonymous (not verified)	174.243.112.246	brian kass	Proprietorship	15064 kass 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.	2020-06-11	brian kass	kass5kass@hotmail.com	dubuque	Iowa	Iowa	kelly kass	jenny McIntyre	Signed	(1) The employer does not elect the employers’ liability coverage.	brian kass	kass5kass@hotmail.com	self	dubuque	Iowa	iowa	Kelly Kass	Jenny McIntyre	Signed
186	2020-06-15 08:03	Anonymous (not verified)	66.188.136.150	Candace Dingler	Proprietorship	280 Trimble Station 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.	2020-06-10	Candace Dingler	kschumacher@tricorinsurance.com	Hogansville	Troup	GA	Russell Masartis	Angie Ords	Signed	(1) The employer does not elect the employers’ liability coverage.	Candace Dingler	kschumacher@tricorinsurance.com	Same	Hogansville	Troup	GA	Russell Masartis	Angie Ords	Signed
189	2020-06-16 16:24	Anonymous (not verified)	173.28.58.2	Perry Engel	Proprietorship	140 2nd Ave NW	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-12	Perry Engel	HRSolutionsContracting@gmail.com	Oelwein	IA	United States	Danette Hager	Tosha Medina	Signed	(1) The employer does not elect the employers’ liability coverage.	Perry Engel	HRSolutionsContracting@gmail.com	Self	Oelwein	IA	United States	Danette Hager	Tosha Medina	Signed
192	2020-06-24 07:42	Anonymous (not verified)	66.188.136.150	Paul Brickley	Proprietorship	558 Franklin Ave. Galesburg, IL 61401	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	Paul Brickley	kschumacher@tricorinsurance.com	Galesburg	Knox	IL	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	Paul Brickley	kschumacher@tricorinsurance.com	Same	Galesburg	Knox	IL	Russell Masartis	Nancy Wortley	Signed
194	2020-06-24 15:24	Anonymous (not verified)	173.16.140.254	Eugene Behle	Proprietorship	3134 6th Ave Des Moines IA 50313	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-24	Eugene Behle III	Bub4bme@gmail.com	Des Moines	Polk	Iowa	Kelly Coluzzi	Mitch Coluzzi	Signed	(1) The employer does not elect the employers’ liability coverage.	Eugene Behle III	Bub4bme@gmail.com	Self	Des Moines	POLK	Iowa	Kelly Coluzzi	Mitch Coluzzi	Signed
196	2020-06-30 23:17	Anonymous (not verified)	72.46.186.211	Artie's Construction	Proprietorship	520 5th Ave Sibley, IA 51249	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.	2020-06-30	Gloria Esther Torres	torrglo@hotmail.com	Sibley	Osceola	Iowa	Laura Barrie	Morgen Gonzalez	Signed	(1) The employer does not elect the employers’ liability coverage.	Gloria Esther Torres	torrglo@hotmail.com	Self	Sibley	Osceola	Iowa	Laura Barrie	Morgen Gonzalez	Signed
197	2020-07-02 09:33	Anonymous (not verified)	66.188.136.150	M & EM Trucking	Proprietorship	216 4th Ave SE 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.	(1) I am not electing the employers’ liability coverage.	2020-07-02	Martin Funke	kschumacher@tricorinsurance.com	Dyersville	Dubuque	IA	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	Martin Funke	kschumacher@tricorinsurance.com	Same	Dyersville	Dubuque	IA	Russell Masartis	Nancy Wortley	Signed
199	2020-07-09 10:49	Anonymous (not verified)	167.142.98.40	Ryan Stott	Proprietorship	1513 Hawthorne Lane	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-09	Ryan Lynn Stott	rlstott@hotmail.com	Jefferson	Greene	Iowa	Brock Chisum	Brian Chisum	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Stott	rlstott@hotmail.com	self	Jefferson	Greene	Iowa	Brock Chisum	Brian Chisum	Signed
200	2020-07-09 10:56	Anonymous (not verified)	167.142.98.40	brian chisum	Proprietorship	168 c.r. 2007 valley view tx	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-09	brian chisum	chisum413@gmail.com	valley view	cooke	tx	lakota larson	john morland	Signed	(1) The employer does not elect the employers’ liability coverage.	brian chisum	chisum413@gmail.com	self	valley view	cooke	tx	lakota larson	john morland	Signed
201	2020-07-09 11:07	Anonymous (not verified)	167.142.98.40	Brock Chisum	Proprietorship	369 Wise Rd., Decatur, TX76234	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-09	Brock Chisum	bchisum@hotmail.com	Decatur, TX	Wise	Texas	Lakota Larson	Ryan Stott	Signed	(1) The employer does not elect the employers’ liability coverage.	Brock Chisum	bchisum@hotmail.com	Self	Decatur	Wise	Texas	Lakota Larson	Ryan Stott	Signed
202	2020-07-10 15:30	Anonymous (not verified)	50.82.95.247	Paulo De Oliveira	Proprietorship	466 Valeen In Belton, MO 64012	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-10	Paulo De Oliveira	paulinhousa1981@gmail.com	Belton	Cass	Missouri	Deanna K Yersin	Ryan S. Johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	Paulo De Oliveira	paulinhousa1981@gmail.com	paulinhousa1981@gmail.com	Belton	Cass	Missouri	Deanna K Yersin	Ryan S. Johnson	Signed
206	2020-07-16 08:18	Anonymous (not verified)	97.64.194.122	Tommy Messino	Proprietorship	205 S Taylor St., Cherry, IL 61317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-10	Tommy Messino	kschumacher@tricorinsurance.com	Cherry	Bureau	IL	Russell Masartis	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Tommy Messino	kschumacher@tricorinsurance.com	Same	Cherry	Bureau	IL	Russell Masartis	Shuree Behr	Signed
207	2020-07-16 13:05	Anonymous (not verified)	173.16.140.254	Steve Kennedy	Proprietorship	5108 SW 13th 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.	2020-07-16	Steve Kennedy	stevekennedy@gmail.com	Des Moines	Polk	Iowa	Jen Echterling	Jake Hibbert	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Kennedy	stevekennedy007@gmail.com	Owner	Des Moines	Polk	Iowa	Jen Echterling	Jake Hibbert	Signed
209	2020-07-19 17:02	Anonymous (not verified)	173.189.166.183	Merle Fox	Proprietorship	314 N Jackson 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.	2020-07-19	Merle T Fox	merletravisfox.79@gmail.com	Lisbon	Linn	Iowa	Dustin Ohlfest	Chelsea Brown	Signed	(1) The employer does not elect the employers’ liability coverage.	Merle Fox	merletravisfox.79@gmail.com	self	Lisbon	Linn	Iowa	Dustin Ohlfest	Chelsea Brown	Signed
210	2020-07-20 13:28	Anonymous (not verified)	75.162.95.97	RM construction	Proprietorship	65 SE 5TH STREET APT 4 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.	2020-07-20	Rafael Marquez	marquezrafael1@outlook.com	Des Moines	Polk IOWA	IOWA	Richard Yanez	Francisco Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Rafael Marquez	marquezrafael1@outlook.com	owner	Des Moines	Polk	IOWA	Richard Yanez	Francisco Garcia	Signed
212	2020-07-20 16:43	Anonymous (not verified)	97.64.164.30	Bernard L. Gradoville D.D.S.	Proprietorship	2800 Ingersoll Ave.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-20	Bernard Gradoville	bgradoville@ingersollfamilydentistry.com	Des Moines	IA	United States	Tricia Wilson	Jack Gradoville	Signed	(1) The employer does not elect the employers’ liability coverage.	Bernard Gradoville	bgradoville@ingersollfamilydentistry.com	self	Des Moines	IA	United States	Tricia Wilson	Jack Gradoville	Signed
214	2020-07-22 14:31	Anonymous (not verified)	66.188.136.150	David Fuller	Proprietorship	19 Riviera Lane, Omro, WI 54963	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-14	David Fuller	kschumacher@tricorinsurance.com	Omro	Winnebago	WI	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	David Fuller	kschumacher@tricorinsurance.com	Same	Omro	Winnebago	WI	Russell Masartis	Nancy Wortley	Signed
217	2020-07-27 14:56	Anonymous (not verified)	72.2.163.232	Calvin Kroger	Proprietorship	48232 292nd St. Hudson, SD 57034	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-27	Calvin Kroger	calvinkroger@gmail.com	Hudson	Lincoln	South Dakota	Robin Anderson	Adam Anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Calvin Kroger	calvinkroger@gmail.com	proprietor	Hudson	Lincoln	South Dakota	Robin Anderson	Adam Anderson	Signed
219	2020-07-31 08:49	Anonymous (not verified)	173.31.147.225	JOHN RUPP	Proprietorship	3110 TYLER AVENUE HARTLEY IA 51346	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-30	JOHN P RUPP	THEELECTRICIANLLC@OUTLOOK.COM	HARTLEY	OBRIEN	IOWA	TAMI KLEIN	KRIS WALKER	Signed	(1) The employer does not elect the employers’ liability coverage.	JOHN P RUPP	THEELECTRICIANLLC@OUTLOOK.COM	SELF	HARTLEY	OBRIEN	IA	TAMI KLEIN	KRIS WALKER	Signed
220	2020-08-02 13:45	Anonymous (not verified)	99.203.112.113	R&G SEAMLESS GUTTERS	Proprietorship	3244 Dubuque Ave, 3244 Dubuque Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-02	Ruben Munoz Haro	munozharoruben@gmail.com	Des Moines	Polk	Estados Unidos	Gabriel Ramirez	Adriana Ramirez	Signed	(1) The employer does not elect the employers’ liability coverage.	Ruben Munoz- R&G SEAMLESS GUTTERS	Munozharoruben@gmail.com	owner	3244 Dubuque Ave Des Moines Iowa 50317	polk	iowa	Gabriel Ramirez	Adriana Ramirez	Signed
221	2020-08-03 12:03	Anonymous (not verified)	167.142.196.238	Israel Moreno	Proprietorship	Po Box 186 Williams, IA 50271	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.	2020-06-12	Israel Moreno	mikjuniormoreno@hotmail.com	Williams	Hamilton	Iowa	Justin J Malloy	Myndi Grimsley	Signed	(1) The employer does not elect the employers’ liability coverage.	Israel Moreno	mikjuniormoreno@hotmail.com	owner	Williams	Hamilton	Iowa	Justin J Malloy	Myndi Grimsley	Signed
222	2020-08-03 16:16	Anonymous (not verified)	204.98.109.114	Norval Craig Michael	Proprietorship	640 NE 47th Place, Des Moines, IA 50313	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-20	Norval Craig Michael	accounts@dickersonmechanical.com	Des Moines	Polk	Iowa	Lisa Linnette Booher	Kathryn Lou Dickerson	Signed	(1) The employer does not elect the employers’ liability coverage.	Nornal Craig Michael	accounts@dickersonmechanical.com	Self Employeed - Sole Proprietor	Des Moines	Polk	Iowa	Lisa Linnette Booher	Kathryn Lou Dickerson	Signed
225	2020-08-05 14:31	Anonymous (not verified)	66.188.136.150	William Brickley	Proprietorship	327 E Prairie St., Wataga, IL 61488	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.	2020-08-03	William Brickley	kschumacher@tricorinsurance.com	Watage	Knox	IL	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	William Brickley	kschumacher@tricorinsurance.com	Same	Wataga	Knox	IL	Russell Masartis	Nancy Wortley	Signed
226	2020-08-07 11:37	Anonymous (not verified)	71.39.227.238	Clinton Luellen	Proprietorship	18591 N Ave, Minburn, IA 50167	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.	2020-08-07	Clinton Luellen	CALuellen@gmail.com	Minburn	Dallas	Iowa	Winette Luellen	Don Richardson	Signed	(1) The employer does not elect the employers’ liability coverage.	Clinton Luellen	CALuellen@gmail.com	Self	Minburn	Dallas	Iowa	Winette Luellen	Don Richardson	Signed
230	2020-08-13 16:59	Anonymous (not verified)	174.217.21.76	Aaron Gilbert	Proprietorship	11864 W 125th St S, Runnells, IA 50237	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.	2020-08-13	Aaron Michael Gilbert	gilbertinpc@msn.com	Runnells	Jasper	Iowa	Bob Coluzzi	Mitch Coluzzi	Signed	(1) The employer does not elect the employers’ liability coverage.	Aaron Michael Gilbert	gilbertinpc@msn.com	Same person	Runnells	Jasper	Iowa	Bob Coluzzi	Mitch Coluzzi	Signed
231	2020-08-13 18:22	Anonymous (not verified)	173.27.28.18	Kelley Contracting	Proprietorship	115 Pinecrest Circle Elk Run Heights, Ia 50707	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.	2020-08-13	Chad Kelley	chadkelley22@gmail.com	Elk Run Heights	Black Hawk	Iowa	Jack Kelley	Jennifer Kelley	Signed	(1) The employer does not elect the employers’ liability coverage.	Kelley Contracting	chadkelley22@gmail.com	Self	Elk Run Heights	Black Hawk	Iowa	Jack Kelley	Jennifer Kelley	Signed
233	2020-08-17 14:24	Anonymous (not verified)	165.225.0.98	Daniel L Knebel	Proprietorship	439 Carroll Blvd, Dunkerton, IA, 50626	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.	2020-08-17	Daniel L Knebel	knebeldan@gmail.com	Dunkerton	Black Hawk	Iowa	Carman M Knebel	Joseph E Knebel	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel L Knebel	knebeldan@gmail.com	Owner	Dunkerton	Black Hawk	Iowa	Carman M Knebel	Joseph E Knebel	Signed
234	2020-08-18 09:13	Anonymous (not verified)	67.55.224.208	Anthony Keahi dba Hawaiian Handyman	Proprietorship	928 8th Ave SE, Sioux Center, IA 51250-2502	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.	2020-08-17	Anthony Keahi	hhkeahi@gmail.com	Sioux Center	Sioux	Iowa	Kyle Blankers	Julia Huisman	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony Keahi	hhkeahi@gmail.com	Self - sole proprietorship	Sioux Center	Sioux	Iowa	Kyle Blankers	Julia Huisman	Signed

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