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:
273	2020-10-05 13:57	Anonymous (not verified)	173.30.54.139	Jackson Exteriors	Proprietorship	705 Cherry Avenue Woodward,ia 50276	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.	2020-10-05	Lucas Jackson	ljajackson41977@gmail.com	Woodward	IA	United States	Cody Roth	Dustin Perry	Signed	(1) The employer does not elect the employers’ liability coverage.	Lucas Jackson	ljajackson41977@gmail.com	Owner	Woodward	Dallas	United States	Cody Roth	Dustin perry	Signed
292	2020-10-27 18:15	Anonymous (not verified)	173.19.162.248	John Lass	Limited Liability Company	6025 SE 16TH CT	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.	2020-10-27	John Lass	johnwlass@gmail.com	Des Moines	IA	United States	Dawn Lass	Gordon Lamp Jr.	Signed	(1) The employer does not elect the employers’ liability coverage.	John Lass	johnwlass@gmail.com	self	Des Moines	IA	United States	Dawn Lass	Gordon Lamp Jr	Signed
293	2020-10-28 06:58	Anonymous (not verified)	173.189.165.102	Boettcher Construction	Proprietorship	PO Box 482, 843 West Business 30	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.	2020-10-28	otto p boettcher	obc32@live.com	Lisbon	IA	iowa	Barb Boettcher	Barb Boettcher	Signed	(1) The employer does not elect the employers’ liability coverage.	otto p boettcher	obc32@live.com	same person	Lisbon	IA	iowa	Barb Boettcher	Barb Boettcher	Signed
330	2020-12-03 08:11	Anonymous (not verified)	208.126.61.46	Hometown Comfort Heating & Cooling, LLC.	Limited Liability Company	1855 280th St. Webster City, Ia. 50595	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.	2020-12-03	Mason Ormesher	hometowncomfortia@gmail.com	Webster City	IA	United States	Kylee Ormesher	Karen Ostrem	Signed	(1) The employer does not elect the employers’ liability coverage.	Mason Ormesher	hometowncomfortia@gmail.com	Owner	Webster City	Hamilton	Iowa	Kylee Ormesher	Karen Ostem	Signed
334	2020-12-07 12:38	Anonymous (not verified)	173.19.190.160	Broadband Installations of Iowa LLC	Limited Liability Company	P.O. Box 728 Carroll, IA 51401	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.	2020-12-07	Charles Wood	cwood.bband@outlook.com	CEDAR RAPIDS	IA	IA	Eva Wood	Tamara Wood	Signed	(1) The employer does not elect the employers’ liability coverage.	Skyla Siech	skylabbi@outlook.com	Offcie Manager	Ely	Linn	Iowa	Melvin Harter	Eddie Bell	Signed
347	2020-12-31 13:44	Anonymous (not verified)	66.129.217.166	Issis Melissa Nunez	Proprietorship	2128 S Riverside Dr. Trl 57, Iowa City, IA 52246	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.	2020-12-01	Issis Melissa Nunez	tonypauljohnson@yahoo.com	Iowa City	IA	United States	Anthony Johnson	Olvin Lanza	Signed	(1) The employer does not elect the employers’ liability coverage.	Issis Melissa Nunez	tonypauljohnson@yahoo.com	Owner	Iowa City	IA	United States	Anthony Johnson	Olvin Lanza	Signed
348	2020-12-31 14:09	Anonymous (not verified)	66.129.217.166	Premier Plus LLC	Limited Liability Company	1930 St Andrews Crt NE, Suite A, Cedar Rapids, IA 52402	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-12-01	Cerby Newton	tonypauljohnson@yahoo.com	Cedar Rapids	IA	United States	Olvin Lanza	Anthony Johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	Cerby Newton	tonypauljohnson@yahoo.com	Owner	Cedar Rapids	IA	United States	Anthony Johnson	Olvin Lanza	Signed
360	2021-01-12 12:08	Anonymous (not verified)	75.162.189.102	Super Green Plus Llc	Limited Liability Company	3020 SE 5th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-12	Damon Berry	theatvfan@gmail.com	Des Moines	IA	United States	Naki Brown	Nakima Brown	Signed	(1) The employer does not elect the employers’ liability coverage.	Super Green Plus	theatvfan@gmail.com	owner	Des Moines	IA	United States	Naki Brown	Nakima Brown	Signed
366	2021-01-18 18:32	Anonymous (not verified)	75.162.57.214	Affordable Exteriors, LLC	Limited Liability Company	802 east COUNTY LINE RD #57	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.	2021-01-18	Destiny Moses	Info@mktdsm.com	DES MOINES	IA	United States	Miguel Angel Garcia Ramirez	Nelly Bekker	Signed	(1) The employer does not elect the employers’ liability coverage.	Destiny Moses	Info@mktdsm.com	owner	DES MOINES	IA	United States	Miguel Garcia	Nellie Bekker	Signed
367	2021-01-21 14:18	Anonymous (not verified)	107.117.168.117	1105 Wade St	Proprietorship	1105 WADE ST	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-03	Jose J Castillo	Jonathancas782@gmail.com	DES MOINES	IA	United States	Jose gaytan	Ruben lopez	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose J Castillo	Jonathancas782@gmail.com	Owner	DES MOINES	IA	United States	Jose gaytan	Ruben lopez	Signed
378	2021-01-29 11:43	Anonymous (not verified)	50.82.21.136	GRAPHIX MASTERS	Limited Liability Company	420 Hamilton St.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-01-29	Klayton Karl Kirkpatrick	klay@graphixmasters.us	Ottumwa	IA	United States	Brian Wilson	Aimee Kirkpatrick	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Klayton Kirkpatrick	klay@graphixmasters.us	Same	Ottumwa	Iowa	United States	Brian Wilson	Aimee Kirkpatrick	Signed
381	2021-02-02 12:46	Anonymous (not verified)	167.142.150.21	T and A Transfer, LLC.	Limited Liability Company	3330 340th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-02	Todd L Ahrenholtz	todd.ahrenholtz123@gmail.com	Manilla	IA	IA	Angela Ahrenholtz	Angela Ahrenholtz	Signed	(1) The employer does not elect the employers’ liability coverage.	Todd L Ahrenholtz	todd.ahrenholtz123@gmail.com	owner	Manilla	Iowa	Iowa	Angela Ahrenholtz	Angela Ahrenholtz	Signed
464	2021-04-07 22:15	Anonymous (not verified)	173.18.251.105	TEMPLEMAN LAWN CARE AND SNOW REMOVAL	Proprietorship	1612 Lomas Circle	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-07	TIM LEE Templeman	nancytempleman@gmail.com	Atlantic	IA	United States	TARA JESSEN	ALFRED WEDE	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	CULLEN AND ASSOCIATES	tammy@cullenins.com	Insurance agent	Atlantic	Cass	Iowa	Tara Jessen	Alfred Wede	Signed
467	2021-04-10 12:21	Anonymous (not verified)	24.252.54.168	Dave and Nancy Preucil Inc.	Proprietorship	13585 Clearview 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.	2021-04-10	Domenico Zurini II	davesspeedwaydz@gmail.com	Council Bluffs	IA	United States	Irven Saar II	Jeffrey Hanke	Signed	(1) The employer does not elect the employers’ liability coverage.	Barbi Zurini	bzurini@gmail.com	Wife	Council Bluffs	IA	United States	Irven Saar II	Jeffrey Hanke	Signed
470	2021-04-13 09:34	Anonymous (not verified)	173.21.135.56	JNZ Recruiting LLC	Limited Liability Company	703 Washington St. Williamsburg, IA 52361	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.	2021-04-07	Javier Nevarez	amanda@burginsuranceagency.com	Williamsburg	IA	IA	Amanda Clubb	Bradley Schaefer	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Javier Nevarez	amanda@burginsuranceagency.com	Self	Williamsburg	Iowa	Iowa	Amanda Clubb	Bradley Schaefer	Signed
495	2021-04-23 11:26	Anonymous (not verified)	98.22.221.1	T & S Industries Inc	Partnership	200 West Jefferson	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-23	Tim Hunter	tands@iowatelecom.net	Afton	IA	IA	Cindy R Harper	Richard Mordock	Signed	(1) The employer does not elect the employers’ liability coverage.	Travelers Insurance	lisa@allplansins.com	agent	Afton	IA	IA	Cindy R Harper	Richard Mordock	Signed
511	2021-05-10 17:53	Anonymous (not verified)	173.24.231.27	QSC Snow Removal	Proprietorship	1211 Carroll Boone IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-10	Vincent A Kaylor	phenox32@gmail.com	Boone	IA	United States	Lori Harvey	Doug Robertson	Signed	(1) The employer does not elect the employers’ liability coverage.	Vincent A Kaylor	phenox32@gmail.com	self	Boone	IA	United States	Lori Harvey	Doug Robertson	Signed
531	2021-05-26 13:02	Anonymous (not verified)	75.162.156.185	Xander Wessels	Limited Liability Company	719 10TH ST NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-26	Alexander Wessels	kprepair@outlook.com	MASON CITY	IA	IA	Dusty Howe	Sadie Lonning	Signed	(1) The employer does not elect the employers’ liability coverage.	Dusty Howe	dusty.mcelectric@gmail.com	Sub Contractor	Mason City	Cerro Gordo	Iowa	Dusty Howe	Sadie Lonning	Signed
563	2021-07-08 12:16	Anonymous (not verified)	173.17.250.209	Forest Avenue Outreach	Limited Liability Company	1600 6th Ave DSM IA 50314	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.	2021-07-08	Maya Bromolson	maya@goodvibesmovement.org	Des Moines	IA	United States	Joel Donaghy	Brian Donaghy	Signed	(1) The employer does not elect the employers’ liability coverage.	Maya Bromolson	maya@goodvibesmovement.org	Executive Director	Des Moines	IA	United States	Joel Donaghy	Brian Donaghy	Signed
565	2021-07-08 13:42	Anonymous (not verified)	173.25.132.255	Communications Construction Services LLC	Limited Liability Company	1315 East 38th Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-08	John McCann Jr	communicationconstructionllc@gmail.com	Des Moines	IA	United States	Laura McCann	David Garza	Signed	(1) The employer does not elect the employers’ liability coverage.	Laura McCann	communicationconstructionllc@gmail.com	spouse	Des Moines	IA	United States	John J McCann Jr	David Christopher Garza III	Signed
569	2021-07-09 12:18	Anonymous (not verified)	173.17.250.209	Forest Ave Outreach dba Good Vibes Movement	Limited Liability Company	1600 6th Ave DSM IA 50314	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.	2021-07-09	Ben Spellman	ben@goodvibesmovement.org	Des Moines	IA	United States	Joel Donaghy	Brian Donaghy	Signed	(1) The employer does not elect the employers’ liability coverage.	Maya Bromolson	maya@goodvibesmovement.org	Executive Director	Des Moines	IA	United States	Joel Donaghy	Brian Donaghy	Signed
591	2021-07-29 16:42	Anonymous (not verified)	138.43.237.95	Choice Ag Services INC	Proprietorship	1841 Firefly Rd, Manchester, IA 52057	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.	2021-07-29	Dustin Fessler	dustin@choiceagservices.com	Manchester	IA	United States	Josh Soppe	Adam Reth	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin Fessler	dustin@choiceagservices.com	Owner	Manchester	Delaware	Iowa	Josh Soppe	Adam Reth	Signed
592	2021-07-29 16:44	Anonymous (not verified)	138.43.237.95	Choice Ag Services INC	Proprietorship	1841 Firefly Rd, Manchester, IA 52057	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.	2021-07-29	Adam Reth	adam@choiceagservices.com	Manchester	IA	United States	Josh Soppe	Adam Reth	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Reth	adam@choiceagservices.com	Owner	Manchester	Delaware	Iowa	Josh Soppe	Dustin Fessler	Signed
602	2021-08-13 22:49	Anonymous (not verified)	208.38.230.125	Granite & More	Limited Liability Company	4730, Tremont Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-14	Jin Chen	clteam563@gmail.com	Davenport	IA	United States	Jin Chen	Betty Song	Signed	(1) The employer does not elect the employers’ liability coverage.	Hong Le	clteam563@gmail.com	Self	Davenport	Scott	Iowa	Jin Chen	Betty Song	Signed
603	2021-08-14 09:39	Anonymous (not verified)	173.20.168.51	Leaf Filter	Proprietorship	3060 Southeast Grimes Boulevard	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-08-14	Francisco Salgado	fsalgado1989@gmail.com	Perry	IA	United States	Wendy Asturias	Susana Romero	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Leaf Filter	macosta@leafhome.com	none	Grimes	Polk	Iowa	Wendy Asturias	Susana Romero	Signed
604	2021-08-14 11:18	Anonymous (not verified)	69.54.119.134	Robert Curry	Limited Liability Company	10759 S 96th Ave W Prairie City IA 50228	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-14	Bob Curry	Gardengal4205@gmail.com	Prairie City	IA	United States	Megan Irwin	Rob Irwin	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Curry	Gardengal4205@gmail.com	Self	Prairie City	IA	United States	Megan Irwin	Rob Irwin	Signed
623	2021-08-30 15:03	Anonymous (not verified)	174.198.77.231	Joe Dawson	Proprietorship	1088, Dogwood Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-30	Joe R Dawson	joerdawson@gmail.com	Coon Rapids	IA	United States	Linda Doran	Megan Specht	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Joe R Dawson	joerdawson@gmail.com	Owner	Coon Rapids	IA	United States	Linda Doran	Megan Specht	Signed
650	2021-09-22 20:46	Anonymous (not verified)	174.198.68.116	Freedom field services	Limited Liability Company	6285 n 67 ave w baxter iowa 50028	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.	2021-09-22	joseph robert cunningham jr	joecunningham1966@protonmail.com	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed	(1) The employer does not elect the employers’ liability coverage.	joseph robert cunningham jr	joecunningham1966@protonmail.com	owner	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed
651	2021-09-22 21:05	Anonymous (not verified)	174.198.68.116	Freedom field services LLC	Limited Liability Company	6285 n 67 ave w. BAXTER IOWA 50028	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.	2021-09-22	joseph robert cunningham jr	joecunningham1966@protonmail.com	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed	(1) The employer does not elect the employers’ liability coverage.	joseph robert cunningham jr	joecunningham1966@protonmail.com	owner	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed
653	2021-09-23 15:03	Anonymous (not verified)	72.46.189.33	Feldkamp Farms Inc	Partnership	5382 170th St 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.	2021-09-23	Harold P Feldkamp	joan@ellerbroekandassociates.com	Sibley	IA	United States	Wade Ellerbroek Jr	Joan Wallace	Signed	(1) The employer does not elect the employers’ liability coverage.	James Wade Ellerbroek Jr	WADE@ELLERBROEKANDASSOCIATES.COM	Agent only	Sibley	IA	United States	Wade Ellerbroek Jr	Joan Wallace	Signed
659	2021-09-28 11:02	Anonymous (not verified)	172.58.83.48	Sean Goodwin	Limited Liability Company	8843 primrose lane Clive IA 50325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-28	Sean Goodwin	simplemanmx@gmail.com	Clive	IA	United States	Kaitlyn meier	Tina meier	Signed	(1) The employer does not elect the employers’ liability coverage.	Sean Goodwin	simplemanmx@gmail.com	Self	Clive	Polk	Iowa	Kaitlyn meier	Tina meier	Signed
667	2021-10-11 19:33	Anonymous (not verified)	104.166.240.24	FS Custom Flooring	Limited Liability Company	5729 NW 92nd street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-11	Filip Sakanovic	filip@fscustomflooring.com	Johnston	IA	United States	Senad Sakanovic	Filip Sakanovic	Signed	(1) The employer does not elect the employers’ liability coverage.	FS Tiling and Ceramics	filip@fscustomflooring.com	N/A	Johnston	IA	United States	Senad Sakanovic	Filip Sakanovic	Signed
677	2021-10-18 11:09	Anonymous (not verified)	69.18.40.109	MR&E,llc	Limited Liability Company	2501 Summer St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-18	Marcie R Gaylord	avisburlington@hotmail.com	Fort Madison	IA	United States	Kim Delap	Teri Coleman	Signed	(1) The employer does not elect the employers’ liability coverage.	Marcie Bollin Gaylord	avisburlington@hotmail.com	President	FORT MADISON	Lee	Iowa	Kim Delap	Teri Coleman	Signed
678	2021-10-18 11:26	Anonymous (not verified)	69.18.40.109	MR&E,llc	Limited Liability Company	2501 Summer St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-18	Linda Hunter	whitandpayt@gmail.com	Burlington	IA	United States	Kim Delap	Teri Coleman	Signed	(1) The employer does not elect the employers’ liability coverage.	Marcie Bollin Gaylord	avisburlington@hotmail.com	President	FORT MADISON	IA	United States	Kim Delap	Teri Coleman	Signed
680	2021-10-18 13:58	Anonymous (not verified)	166.181.86.88	Gerald Jerome	Proprietorship	2668 Wapsi Ridge Dr. Walker, IA 52352	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.	2021-10-18	Gerald Jerome	geraldjerome373@ymail.com	Walker	IA	United States	Benjamin J Barkalow	James M. Barkalow	Signed	(1) The employer does not elect the employers’ liability coverage.	Gerald Jerome	geraldjerome373@ymail.com	Self employed	Walker	Linn	Iowa	Benjamin J Barkalow	James M Barkalow	Signed
683	2021-10-20 09:39	Anonymous (not verified)	173.23.253.122	Superior Floors	Limited Liability Company	704 41st Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-20	Ron Shannon	ronshannon3831@gmail.com	West Des Moines	IA	United States	Virginia Shannon	Virginia Shannon	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron Shannon	ronshannon3831@gmail.com	Self	West Des Moines	IA	United States	Virginia Shannon	Virginia Shannon	Signed
689	2021-10-25 14:38	Anonymous (not verified)	107.197.114.249	Brookstin Flooring LLC	Limited Liability Company	1702 Brown Deer Rd Coralville IA 52241	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-10-25	Richard T Klemesrud	rickklemesrud@gmail.com	CORALVILLE	IA	United States	Brian Woods	Sherry Woods	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Richard T Klemesrud	rickklemesrud@gmail.com	Myself / Owner	CORALVILLE	IA	United States	Brian Woods	Sherry Woods	Signed
696	2021-10-28 10:33	Anonymous (not verified)	173.18.85.215	Saunders Construction	Proprietorship	7304 SW 14th St 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.	2021-10-28	Charles A Saunders	charlessaunders901@gmail.com	Des Moines	IA	United States	Ramona Mitchell	Rasheedah Gasaway	Signed	(1) The employer does not elect the employers’ liability coverage.	Charles Saunders	charlessaunders901@gmail.com	Owner	Des Moines	Polk	Iowa	Ramona Mitchell	Rasheedah Gasaway	Signed
702	2021-11-01 09:23	Anonymous (not verified)	173.28.195.56	Garcia Snow Removal	Limited Liability Company	213 E 7th Street, West Liberty, Iowa 52776	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.	2021-11-01	Benji A Garcia	garciabenji23@gmail.com	West Liberty	IA	Norway	Luis Ordenana-Choez	Vicente Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Benji Garcia	garciabenji23@gmail.com	Member	West Liberty	Muscatine	Iowa	Luis Ordenana-Choez	Vicente Garcia	Signed
752	2021-11-17 08:22	Anonymous (not verified)	166.181.82.81	Michael sprout	Limited Liability Company	1208 N THORNWOOD AVE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-14	Michael Sprout	1293newhome@gmail.com	Davenport	IA	IA	Mike smith	Doug palmer	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Sprout	1293newhome@gmail.com	Geico	Davenport	IA	IA	Mike smith	Doug palmer	Signed
760	2021-11-21 16:31	Anonymous (not verified)	107.77.206.216	Jacob Odean	Limited Liability Company	6634 Lorton CT. Davenport IA 52807	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-21	Jacob James Odean	jodean5725@gmail.com	DAVENPORT	IA	United States	James Odean	Vickie Odean	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob James Odean	jodean5725@gmail.com	Same	DAVENPORT	SCOTT	United States	James Odean	Vickie Odean	Signed
773	2021-11-24 14:48	Anonymous (not verified)	24.149.18.237	The Ragged Edge Art Bar and Gallery	Limited Liability Company	504 Bluff Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-24	Kendra Wohlert	kwohlert43@gmail.com	CEDAR FALLS	IA	United States	Theresa Johnson	Danette Priebe	Signed	(1) The employer does not elect the employers’ liability coverage.	Kendra Wohlert	kwohlert43@gmail.com	self	CEDAR FALLS	IA	United States	Theresa Johnson	Danette Priebe	Signed
779	2021-12-06 10:43	Anonymous (not verified)	172.83.21.144	Munn Enterprises LLC	Limited Liability Company	118 14th Avenue South	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.	2021-12-06	Douglas A Munn	munnent1328@gmail.com	Clear lake	IA	IA	Troy Thomas Munn	Marjorie Marie Munn	Signed	(1) The employer does not elect the employers’ liability coverage.	Troy Munn	Troy@munnentllc.com	Owner	Clear Lake	Cerro Gordo	Iowa	Troy Thomas Munn	Marjorie Marie Munn	Signed
782	2021-12-08 10:11	Anonymous (not verified)	173.21.158.248	Barry Duncan	Proprietorship	2020 S.E. Four Seasons Dr., Ankeny IA 50021	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-08	BARRY DUNCAN	bduncan1452@gmail.com	Ankeny	IA	Iowa	Kathy Belieu	Summer Belieu-Slemp	Signed	(1) The employer does not elect the employers’ liability coverage.	BARRY DUNCAN	bduncan1452@gmail.com	Self	Ankeny	Polk	Iowa	Kathy Belieu	Summer Belieu-Slemp	Signed
784	2021-12-09 09:03	Anonymous (not verified)	97.64.139.42	JZ INC	Limited Liability Company	2509 Ne 10th CT Grimes Iowa 50111	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.	2021-12-08	James Scott Zastrow	Zastrow74@gmail.com	Grimes	IA	United States	NIcole Zastrow	Kevan Wiggins	Signed	(1) The employer does not elect the employers’ liability coverage.	James scott Zastrow	loffredon@aol.com	Self	Grimes	IA	United States	nicole zastrow	Kevan wiggins	Signed
795	2021-12-15 07:47	Anonymous (not verified)	173.22.84.26	LAMPE APPLIANCE SERVICE, Inc	Proprietorship	210 29TH ST NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-15	Douglas James Lampe	lampeappliance@gmail.com	CEDAR RAPIDS	IA	IA	John Kenneth Lampe	Kenneth Roman Lampe	Signed	(1) The employer does not elect the employers’ liability coverage.	Douglas James Lampe	lampeappliance@gmail.com	Vice President	Cedar Rapids	Linn	Iowa	John Kenneth Lampe	Kenneth Roman Lampe	Signed
815	2021-12-28 12:29	Anonymous (not verified)	173.29.239.122	Comtek, Inc.	Proprietorship	3702 NW 13th St. Ankeny, Iowa 50023	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.	2021-12-28	Micheal D. Qualley	mqcomtek@gmail.com	ANKENY	IA	United States	Jacque Blackman	Jeffery Keipper	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacque Blackman	jblackman@grimesfinancialgroup.com	client	Grimes	Polk	Iowa	Jacque Blackman	Jeffery Keipper	Signed
825	2022-01-06 21:02	Anonymous (not verified)	174.213.145.18	Two Brothers Tile llc	Proprietorship	1244 72nd St Windsor heights ia 50324	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-06	Senahid Mujkanovic	xbosanacbax17@gmail.com	Windsor Heights	IA	United States	Ramiza kadric	Senad mujkanovic	Signed	(1) The employer does not elect the employers’ liability coverage.	Senahid Mujkanovic	xbosanacbax17@gmail.com	Owner	Windsor Heights	IA	United States	Ramiza kadric	Senad mujkanovic	Signed
842	2022-01-17 16:29	Anonymous (not verified)	172.58.87.164	The Green Boys	Limited Liability Company	55 Southeast Windfield Parkway	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-17	Emilio Belismelis	emiliobelismelis87@gmail.com	Waukee	IA	United States	Lorena Belismelis	Lorena Belismelis	Signed	(1) The employer does not elect the employers’ liability coverage.	The Green Boys	emiliobelismelis87@gmail.com	Owner	Waukee	IA	United States	Emilo Belismelis	Maria Belismelis	Signed
845	2022-01-20 09:06	Anonymous (not verified)	208.126.69.10	KenX Pest Control	Limited Liability Company	350 2nd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-20	Ken YARRINGTON	kenxpestcontrol@hotmail.com	Truro	IA	IA	James Gage	Kent Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Kenneth Charles Yarrington	kenxpestcontrol@hotmal.com	Myself	Truro	IA	IA	James Gage	Kent Smith	Signed

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