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:
1863	2023-10-06 12:24	Anonymous (not verified)	94.188.207.223	ADRIAN CAZARES HERNANDEZ	Proprietorship	409 N 16TH PL, ESTHERVILLE, IA 51334	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-06	ADRIAN CAZARES HERNANDEZ	JOEL@WALKERINSURANCE.COM	ESTHERVILLE	EMMET	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	ADRIAN CAZARES HERNANDEZ	JOEL@WALKERINSURANCEIA.COM	SELF	ESTHERVILLE	EMMET	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1873	2023-10-20 09:25	Anonymous (not verified)	94.188.207.228	GC Hauling LLC	Limited Liability Company	310 North 18th Street, Indianola, IA, 50125	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-20	Garrett Joseph Claerhout	gjclaerhout@hotmail.com	INDIANOLA	IA	IA	Kirsten Claerhout	Jay Claerhout	Signed	(1) The employer does not elect the employers’ liability coverage.	Garrett Joseph Claerhout	gjclaerhout@hotmail.com	Same Person	INDIANOLA	IA	IA	Kirsten Claerhout	Jay Claerhout	Signed
1874	2023-10-22 11:54	Anonymous (not verified)	94.188.205.166	Midwest UAV LLC	Limited Liability Company	1400 15th St SE Bondurant Iowa 50035	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-22	Kaleb Thomas Trammell	kttrammell05@gmail.com	Bondurant	Polk	IA	Alan Willis	Danielle Trammell	Signed	(1) The employer does not elect the employers’ liability coverage.	Kaleb Thomas Trammell	kttrammell05@gmail.com	Owner	Bondurant	Polk	IA	Alan Willis	Danielle Trammell	Signed
1877	2023-10-23 15:49	Anonymous (not verified)	94.188.207.228	Craig Michael Wilson	Proprietorship	24538 118th Street, Columbus Junction, IA 52738	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-16	Craig Michael Wilson	tripod109@hotmail.com	Columbus Junction	Louisa	IA	Brenda Wilson	Ruger Dean	Signed	(1) The employer does not elect the employers’ liability coverage.	Craig Michael Wilson	tripod109@hotmail.com	Self	Columbus Junction	Louisa	IA	Brenda Wilson	Ruger Dean	Signed
1882	2023-10-27 10:40	Anonymous (not verified)	94.188.205.166	Ron's SIding and Construction	Proprietorship	6097 26th 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.	2025-02-02	Ron Heggebo	heggebojessica@yahoo.com	Vinton	Benton	IA	Jessica Heggebo	Jessica Heggebo	Signed	(1) The employer does not elect the employers’ liability coverage.	Ronnie Heggebo	heggebojessica@yahoo.com	self	Vinton	Benton	IA	Jessica Heggebo	Jessica Heggebo	Signed
1883	2023-10-27 10:49	Anonymous (not verified)	94.188.207.228	Ron's SIding and Construction	Proprietorship	6097 26th 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.	2023-10-27	Ron Heggebo	heggebojessica@yahoo.com	Vinton	Benton	IA	Jessica Heggebo	Jessica Heggebo	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron Heggebo	heggebojessica@yahoo.com	Self	Vinton	Benton	IA	Jessica Heggebo	Jessica Heggebo	Signed
1884	2023-10-27 18:32	Anonymous (not verified)	94.188.205.177	J&M dry wall	Proprietorship	948 Kern St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-27	Melecio Zacarias-Cano	Meleciozacarias29@gmail.com	Waterloo	Black hawk	IA	Luis flores	Luis flores	Signed	(1) The employer does not elect the employers’ liability coverage.	Melecio Zacarias-Cano	Meleciozacarias29@gmail.com	Self	Waterloo	Black hawk	IA	Luis Flores	Luis flores	Signed
1889	2023-11-01 06:44	Anonymous (not verified)	94.188.207.226	Williams Hardwood Flooring LLC	Limited Liability Company	P.O. Box 22 Marion, Ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-01	Chad Everett William	williamshardwoodflooringllc@gmail.com	Anamosa	Jones	IA	Tara Williams	Sarah Williams	Signed	(1) The employer does not elect the employers’ liability coverage.	Chad E Williams	williamsharfwoodflooringllc@gmail.com	Me	Anamosa	Jones	IA	Tara Williams	Sarah Williams	Signed
1890	2023-11-01 19:22	Anonymous (not verified)	94.188.207.228	JACK SCHADE	Proprietorship	911 Broad St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-01	jack allan schade	jackschade@yahoo.com	Plymouth	IA	IA	jack allan schade	jack allan schade	Signed	(1) The employer does not elect the employers’ liability coverage.	jack allan schade	jackschade@yahoo.com	self	Plymouth	IA	IA	jack allan schade	jack allan schade	Signed
1891	2023-11-02 06:24	Anonymous (not verified)	94.188.207.225	DOC Services	Proprietorship	3313 , E 7th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-01	Quentin Ferguson	1quensy@gmail.com	Des Moines	Polk	IA	Dione Fergsuon	Quensy Ferguson	Signed	(1) The employer does not elect the employers’ liability coverage.	Quentin Ferguson	1quensy@gmail.com	Self	Des Moines	Polk	Ia	Dione Ferguson	Quensy Ferguson	Signed
1892	2023-11-02 12:24	Anonymous (not verified)	94.188.205.169	TREJO'S CONSTRUCTION LLC	Limited Liability Company	1113 L AVE, 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.	2023-11-02	CHARVEL TREJO	levrach@yahoo.com	MILFORD	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	CHARVEL TREJO	levrach@yahoo.com	SELF	MILFORD	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed
1893	2023-11-02 14:39	Anonymous (not verified)	94.188.205.177	Dagoberto Nuñez	Proprietorship	Iowa city	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-02	Dagoberto Nuñez	nunezdagoberto730@gmail.com	833 basswood ln iowa city	Johnson	IA	Darwin salgado	Ramon nuñez	Signed	(1) The employer does not elect the employers’ liability coverage.	Dagoberto Nuñez	nunezdagoberto730@gmail.com	Yo mismo	Iowa city	Johnson	IA	Darwin Salgado	Ramon nuñez	Signed
1894	2023-11-03 10:02	Anonymous (not verified)	94.188.205.167	ASHLEY QUAIL DBA: RUSTIC ROOTS SALON	Proprietorship	33596 SCHANY DR, RUTHVEN, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-03	ASHLEY QUAIL	ashley-mazzanti@hotmail.com	RUTHVEN	PALO ALTO	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	ASHLEY QUAIL	ashley-mazzanti@hotmail.com	SELF	RUTHVEN	PALO ALTO	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1895	2023-11-03 12:21	Anonymous (not verified)	94.188.207.227	Oxbo LLC	Limited Liability Company	2528 Evergreen Ave. Red Oak, IA 51566	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-03	Mettra Sperling	sperlingrose66@gmail.com	Red Oak	Montgomery	IA	Chantal Sperling	Derek Penry	Signed	(1) The employer does not elect the employers’ liability coverage.	Mettra Sperling	sperlingrose66@gmail.com	Self	Red Oak	Montgomery	IA	Chantal Sperling	Derek Penry	Signed
1897	2023-11-06 09:12	Anonymous (not verified)	94.188.205.177	Matthew Jones	Limited Liability Company	124 NE 49th 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.	2023-11-06	Matthew Jones	mjj4242@gmail.com	Ankeny	Polk	IA	Duan Willform	AJ Giebelstein	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Jones	mjj4242@gmail.com	Self	Ankeny	Polk	IA	AJ Giebelstein	Duan Willform	Signed
1898	2023-11-09 09:56	Anonymous (not verified)	94.188.207.227	RC Restoration LLC	Limited Liability Company	991 June Drive, Dubuque, IA 52003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-09	Luke Hoffmann	luke@rentcube.com	Dubuque	Dubuque	Iowa	Randi Taylor	Carla Martin	Signed	(1) The employer does not elect the employers’ liability coverage.	Luke Hoffman	luke@rentcube.com	Owner	Dubuque	Dubuque	IA	Randi Taylor	Carla Martin	Signed
1907	2023-11-15 09:45	Anonymous (not verified)	94.188.205.168	Dan Taylor	Proprietorship	1422 State ST.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-15	Daniel Taylor	mailrunner1958@gmail.com	Mason City	Cerro Gordo	IA	Bob Smith	Dave Clark	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Taylor	mailrunner1958@gmail.com	employee	Mason City	Cerro Gordo	IA	Bob Smith	Dave Clark	Signed
1910	2023-11-15 13:06	Anonymous (not verified)	94.188.207.228	RODRIGUEZ ENTERPRISES III INC	Limited Liability Company	905 W US HIGHWAY 30 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.	2023-11-14	MAURO RODRIGUEZ	mauro15o1@hotmail.com	CARROLL	CARROLL	IOWA	GONZALO MUNOZ	SILVIA CHAVEZ	Signed	(1) The employer does not elect the employers’ liability coverage.	MAURO RODRIGUEZ	mauro15o1@hotmail.com	OWNER	CARROLL	CARROLL	IA	GONZALO MUNOZ	SILVIA CHAVEZ	Signed
1912	2023-11-16 08:40	Anonymous (not verified)	94.188.205.175	JC LANDSCAPING & LAWN CARE	Proprietorship	4940 E. SHERIDAN AVE DES MOINES, IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-16	CLAUDIA TORO PINEDA	CLAUDIAMEP@HOTMAIL.COM	DES MOINES	POLK	IA	BRENDA REEDY	ADAM SMITH	Signed	(1) The employer does not elect the employers’ liability coverage.	CLAUDIA TORO PINEDA	CLAUDIAMEP@HOTMAIL.COM	SELF	DES MOINES	POLK	IA	BRENDA REEDY	ADAM SMITH	Signed
1913	2023-11-20 13:48	Anonymous (not verified)	94.188.205.167	KWF SALES INC	Proprietorship	216 WINDFLOWER 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.	2023-11-20	KRISTI A WOODLEY-FLANSBURG	Kwflansburg@gmail.com	SOLON	Iowa	Iowa	ZACH GRANT	TOM SIMPSON	Signed	(1) The employer does not elect the employers’ liability coverage.	KRISTI A WOODLEY-FLANSBURG	Kwflansburg@gmail.com	SELF	SOLON	IA	IA	ZACH GRANT	TOM SIMPSON	Signed
1916	2023-11-21 12:31	Anonymous (not verified)	94.188.205.174	DC Painting	Proprietorship	205 Astor St, Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-03	Damion Clement	gcort06@gmail.com	Des Moines	Polk	IA	Brandi Haight	Dennis Clement	Signed	(1) The employer does not elect the employers’ liability coverage.	Damion Clement	gcort06@gmail.com	Owner	205 Astor Street	Polk	IA	Brandi Haight	Dennis Clement	Signed
1919	2023-11-21 14:11	Anonymous (not verified)	94.188.207.227	Refined Construction	Limited Liability Company	4148 Mattern 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.	2023-11-21	Dustin Martin	dudtin.martin106@gmail.com	Des Moines	Polk	IA	Kelsey Baldinelli	Brandi Martin	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin Martin	dustin.martin106@gmail.com	Sole officer	Des Moines	Polk	IA	Kelsey Baldinelli	Brandi Martin	Signed
1920	2023-11-22 08:40	Anonymous (not verified)	94.188.205.166	Demolition Services of Iowa, llc	Limited Liability Company	221 North Grant Ave., Elkhart, IA 50073	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-22	William Albert Halterman	DemolitionServicesIA@gmail.com	ELKHART	IA	United States	Ashley Whitehill	Zach Whitehill	Signed	(1) The employer does not elect the employers’ liability coverage.	William Albert Halterman	DemolitionServicesIA@gmail.com	self	Elkhart	Polk	IA	Ashley Nicole Lee Whitehill	Zachery Allen Whitehill	Signed
1929	2023-11-30 10:46	Anonymous (not verified)	94.188.207.225	White Masonry, Inc.	Proprietorship	15141 Bluff Trl., Carlisle, IA 50047	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-30	Jeff White	whitemasonry1979@hotmail.com	Carlisle	IA	IA	Cathleen Marie White	Sam Jeffrey White	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeffrey Dean White	WHITEMASONRY1979@HOTMAIL.COM	Self	CARLISLE	ia	ia	Cathleen Marie White	Sam Jeffrey White	Signed
1931	2023-12-01 18:01	Anonymous (not verified)	94.188.207.225	Jay Wang	Limited Liability Company	16672 Verona Hills Dr, 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.	2023-12-01	Jay Wang	jaywang@wasabidsm.com	Clive	US	IA	WenHui chen	Yingna Zheng	Signed	(1) The employer does not elect the employers’ liability coverage.	Jay Wang	Jaywang@wasabidsm.com	Self	Clive	US	IA	WenHui Chen	Yingna Zheng	Signed
1935	2023-12-02 18:34	Anonymous (not verified)	94.188.207.229	Wasabi Johnston LLC	Limited Liability Company	8184 Birchwood Ct, Johnston IA 50131	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-02	Jay Wang	jaywang@wasabidsm.com	Clive	Dallas	IA	Engjin zheng	yingna Zheng	Signed	(1) The employer does not elect the employers’ liability coverage.	Jay Wang	jaywang@wasabidsm.com	self	Clive	Dallas	IA	Wenhui Cheng	Enjing Zheng	Signed
1939	2023-12-05 14:32	Anonymous (not verified)	94.188.207.229	PJ Trucking Unlimited LLC	Limited Liability Company	2617 380th 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.	2023-12-05	Peggy Jensen	pegandhalj@gmail.com	Farragut	US	IA	Darlene	Julie Ann Marshsll	Signed	(1) The employer does not elect the employers’ liability coverage.	Peggy Jensen	pegandhalj@gmail.com	self	Farragut	US	IA	Darlene Carpenter	Julie Marshall	Signed
1941	2023-12-06 11:52	Anonymous (not verified)	94.188.205.167	GUEVARA CONCRETE LLC	Limited Liability Company	26 WESTVIEW DR 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.	2023-12-06	SAUL GUEVARA MEZA	ESMEJ2513@GMAIL.COM	MILFORD	DICKINSON	IA	TAMI SUE KLEIN	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	SAUL GUEVARA MEZA	ESMEJ2513@GMAIL.COM	SELF	MILFORD	DICKINSON	IA	TAMI SUE KLEIN	JENNIFER JANET YOUNGWIRTH	Signed
1947	2023-12-07 16:01	Anonymous (not verified)	94.188.205.176	Reinier Construction LLC	Limited Liability Company	1406 Linden 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.	2023-12-07	David J Reinier	reinierconst@aol.com	Des Moines	Polk	IA	PEGGY A ROHDE	Douglas E Rohde	Signed	(1) The employer does not elect the employers’ liability coverage.	PEGGY A ROHDE	dnprohde@msn.com	Bookkeeper	Polk City	Polk	IA	Douglas E Rohde	Stacie L Miller	Signed
1953	2023-12-12 15:38	Anonymous (not verified)	94.188.207.226	Ryan Gideon	Proprietorship	9320 Elmcrest Dr Norwalk, Ia 50211	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-12	Ryan Gideon	rgid8403@gmail.com	Norwalk	Warren	IA	Jim Lane	Jim Lane	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Gideon	rgid8403@gmail.com	Owner	Norwalk	Warren	IA	jim Lane	Jim Lane	Signed
1954	2023-12-13 13:51	Anonymous (not verified)	94.188.207.227	Beeson Trucking LLC	Limited Liability Company	219 Tilden St Kingsley IA 51028	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-13	Jeremy Beeson	jeremy4k78@yahoo.com	Kingsley	Plymouth	IA	Katherine Weaver	Darla Robley	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeremy Beeson	jeremy4k78@yahoo.com	Self	Kingsley	Plymouth	IA	Katherine Weaver	Darla Robley	Signed
1960	2023-12-16 11:58	Anonymous (not verified)	94.188.207.227	Landeros Framing	Proprietorship	2418 E 37th 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.	2023-12-16	Francisco Javier Landeros Garcia	garcialanderosfranciscojavier@gmail.com	Des Moines	IA	IA	Mirna Ruby	Jose Gaytan	Signed	(1) The employer does not elect the employers’ liability coverage.	Francisco Javier Landeros Garcia	garcialanderosfranciscojavier@gmail.com	owner	Des Moines	IA	IA	Mirna Ruby	Jose Gaytan	Signed
1964	2023-12-22 10:19	Anonymous (not verified)	94.188.207.224	Dale Pahl	Proprietorship	711 N. 1St. B105 Eldridge IA 52748	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-21	Dale Pahl	Pada7910@gmail.com	Eldridge	Scott	Iowa	Samantha weston	Rick mayerhofer	Signed	(1) The employer does not elect the employers’ liability coverage.	Dale	Pada7910@gmail.com	Self	Eldridge	Scott	IA	Samantha weston	Rick Mayerhofer	Signed
1965	2023-12-22 10:23	Anonymous (not verified)	94.188.207.229	Shawn Cooney	Proprietorship	4425 Ne 34th 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.	2023-12-22	Shawn Nelson Cooney	shawncooney59@gmail.com	Des Moines	polk	IA	Marie Cooney	Shawntel Cooney	Signed	(1) The employer does not elect the employers’ liability coverage.	Shawn Cooney	shawncooney59@gmail.com	Myself	Des Moines	polk	IA	Marie Cooney	Shawntel Cooney	Signed
1970	2023-12-29 10:01	Anonymous (not verified)	94.188.205.168	Beatrice Banura	Proprietorship	14511 Bentwood Dr, Urbandale IA 50323	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-29	Beatrice Banura	banurabeatrice4@gmail.com	Urbandale	Dallas	IA	Priscilla Saina	Gideon Saina	Signed	(1) The employer does not elect the employers’ liability coverage.	Beatrice Banura	banurabeatrice4@gmail.com	Self employed	Urbandale	IA	IA	Priscilla Saina	Gideon Saina	Signed
1972	2024-01-02 14:19	Anonymous (not verified)	94.188.205.174	Parker Trucking LLC	Limited Liability Company	1507 Greene Street Adel, IA 50003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-02	Michael Craig Parker	mcparker31@msn.com	Adel	Dallas	Iowa	Jessie Rynearson	Melisha Rynearson	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Parker	mcparker31@msn.com	Owner/Memeber	Adel	Dallas	IA	Jessie Rynearson	Melishia Rynearson	Signed
1975	2024-01-04 15:42	Anonymous (not verified)	94.188.207.229	Blake S. Judisch Masonry LLC	Limited Liability Company	510 South Fulton St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-04	Blake Judisch	blakejudisch@gmail.com	Shell rock	Butler	IA	Kali Judisch	Terri Thomsen	Signed	(1) The employer does not elect the employers’ liability coverage.	Blake Judisch	blalejudisch@gmail.com	Owner	Shell rock	Butler	IA	Kali Judisch	Terri Thomsen	Signed
1976	2024-01-04 15:48	Anonymous (not verified)	94.188.207.224	Brawdy Services	Proprietorship	7029 Prairie 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.	2024-01-01	Victor Brawdy	heather.l.brawdy@gmail.com	Urbandale	Polk	IA	Summer Munoz	Jennifer Wolters	Signed	(1) The employer does not elect the employers’ liability coverage.	Victor Brawdy	vb69ia@gmail.com	Self	Urbandale	Polk	IA	Summer Munox	Jennifer Wolters	Signed
1977	2024-01-05 13:25	Anonymous (not verified)	94.188.207.228	BOYOK BUILDS, LLC	Limited Liability Company	25395 140TH ST, SPIRIT LAKE, IA 51360	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-04	VITALE BOYOK	BOYOK68@GMAIL.COM	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	VITALE BOYOK	BOYOK68@GMAIL.COM	SELF	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1978	2024-01-08 13:28	Anonymous (not verified)	94.188.205.167	TYREL GIBSON	Proprietorship	2004 CHICAGO AVE SPIRIT LAKE, IA 51360	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-08	TYREL GIBSON	TY11TEKFALL@GMAIL.COM	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	TYREL GIBSON	TY11TEKFALL@GMAIL.COM	SELF	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1982	2024-01-11 12:29	Anonymous (not verified)	94.188.205.166	Grace Justine	Proprietorship	405 Northview Drive	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-11	Grace Justine Wandera / Independent Contractor	justine.wandera@candeoiowa.org	Waukee	IA	IA	Grace Justine Wandera / Independent Contractor	Grace Justine Wandera / Independent Contractor	Signed	(1) The employer does not elect the employers’ liability coverage.	Grace Justine Wandera / Independent Contractor	justine.wandera@candeoiowa.org	own	Waukee	IA	IA	Grace Justine Wandera / Independent Contractor	Grace Justine Wandera / Independent Contractor	Signed
1983	2024-01-11 13:02	Anonymous (not verified)	94.188.205.168	r&k propety solutions	Proprietorship	po box 53 cedar rapids iowa 52406	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-11	roy rohwedder	rohwedder.roy@yahoo.com	Cedar Rapids	linn	ia	Brian Ashlock	tim vaske	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Ashlock	brian@tricounty-iowa.com	General Manager	Center Point	Benton	ia	Tim Vaske	Roy Rohwedder	Signed
1984	2024-01-15 17:33	Anonymous (not verified)	94.188.207.227	Jay Wang	Limited Liability Company	8481 Birchwood Ct, Johnston	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-15	Jay Wang	jaywang@wasabidsm.com	Clive	US	IA	Yingna Zheng	Qiaoqiao Li	Signed	(1) The employer does not elect the employers’ liability coverage.	Jay Wang	jaywang@wasabidsm.com	Self	Clive	US	IA	Yingna Zheng	Qiaoqiao Li	Signed
1988	2024-01-16 15:22	Anonymous (not verified)	94.188.205.176	Harmons Home Services LLC	Limited Liability Company	605 w Cedar st, Cherokee, IA, 51012	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-16	Shawn Michael Harmon	harmonsheatingandair@gmail.com	Cherokee	Ia	United States	Shawn Harmon	Sara Harmon	Signed	(1) The employer does not elect the employers’ liability coverage.	Shawn Michael Harmon	Harmonsheatingandair@gmail.com	Self	Cherokee	Cherokee	IA	Shawn Harmon	Sara Harmon	Signed
1989	2024-01-16 17:13	Anonymous (not verified)	94.188.205.168	Xcel Electric LLC	Limited Liability Company	1142 Columbus Dr Waterloo 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.	2024-01-16	Haris Mumic	h.mumic@hotmail.com	Waterloo	Black Hawk	IA	Minea Skrgic-Mumic	Elvis Mumic	Signed	(1) The employer does not elect the employers’ liability coverage.	Haris Mumic	h.mumic@hotmail.com	Owner/Employer	waterloo	Black Hawk	IA	Minea Skrgic-Mumic	Elvis Mumic	Signed
1997	2024-01-25 11:09	Anonymous (not verified)	94.188.207.225	Abstract Associates of Iowa Inc.	Proprietorship	822 Central Ave Ste 304 Fort Dodge, IA 50501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-21	Ted Hugghins	tjhugghins@abstractassociatesofiowa.com	Fort Dodge	Webster	Iowa	Mariah Ayala	Bennett O'Connor	Signed	(1) The employer does not elect the employers’ liability coverage.	Ted Hugghins	tjhugghins@abstractassociatesofiowa.com	President	Fort Dodge	Webster	IA	Mariah Ayala	Bennett O'Connor	Signed
2000	2024-01-26 10:05	Anonymous (not verified)	94.188.205.177	Nick Myers Construction	Proprietorship	4736 Candlewick Drive, Norwalk, IA 50211	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-26	Nicholas Myers	myersnicholasj@gmail.com	Norwalk	Warren	Iowa	John Myers	Brenda Myers	Signed	(1) The employer does not elect the employers’ liability coverage.	Nicholas Myers	nickmyersconstruction@gmail.com	Owner	Norwalk	IA	IA	John Myers	Brenda Myers	Signed
2002	2024-01-26 17:00	Anonymous (not verified)	94.188.207.228	Legacy Group Consulting	Limited Liability Company	3721 Coppermill Rd NE, 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.	2024-01-26	John A Scott	legacygrpconsulting@gmail.com	Cedar Rapids	Linn	IA	Barbara Scott	Robert Moore	Signed	(1) The employer does not elect the employers’ liability coverage.	John A Scott	legacygrpconsulting@gmail.com	Owner	Cedar Rapids	Linn	IA	Barbara Scott	Robert Moore	Signed
2003	2024-01-28 12:38	Anonymous (not verified)	94.188.205.169	Wasabi Urbandale LLC	Limited Liability Company	2301 Rocklyn Dr, Urbandale IA 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-01	Jay Wang	jaywang@wasabidsm.com	Clive	Dallas	IA	Ajdin Nadarich	Jeremy Boysen	Signed	(1) The employer does not elect the employers’ liability coverage.	Jay Wang	jaywang@wasabidsm.com	Self	Clive	Dallas	IA	Lisa Lee	Yingna Zheng	Signed
2007	2024-01-29 13:13	Anonymous (not verified)	94.188.205.174	Saratoga Seamless Gutters LLC	Limited Liability Company	10328 Howard Ave, Lime Springs, IA 52155	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-29	Michael Langlais	saratogaseamlessgutters@gmail.com	Lime Springs	Howard	IA	Amanda Doty	Michaela Langlais	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Langlais	saratogaseamlessgutters@gmail.com	Owner	Lime Springs	Howard	IA	Amanda Doty	Michaela Langlais	Signed

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