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:
455	2021-03-31 13:35	Anonymous (not verified)	66.188.136.150	Cody Pazicni	Proprietorship	222 Lake Shore Dr. Simpsonville, KY 40067	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-29	Cody Pazicni	kschumacher@tricorinsurance.com	Simpsonville	Shelby	KY	Russell Masartis	Jordan Pape	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody Pazicni	kschumacher@tricorinsurance.com	Same	Simpsonville	Shelby	KY	Russell Masartis	Jodan Pape	Signed
458	2021-04-05 11:59	Anonymous (not verified)	66.188.136.150	Joseph Chance	Proprietorship	815 Richards Dr. Shorewood, IL 60404	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-29	Joseph Chance	kschumacher@tricorinsurance.com	Shorewood	Will	IL	Russell Masartis	Amanda Seeberger	Signed	(1) The employer does not elect the employers’ liability coverage.	Joseph Chance	kschumacher@tricorinsurance.com	Same	Shorewood	Will	IL	Russell Masartis	Amanda Seeberger	Signed
503	2021-05-05 11:27	Anonymous (not verified)	50.82.130.211	Davonius Reed	Limited Liability Company	1913 Upton Avenue, Waterloo IA 50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-01	Davonius Reed	cmins_re@mchsi.com	Waterloo	Black Hawk	IA	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Davonius Reed	cmins_re@mchsi.com	Self	Waterloo	Black Hawk	IA	Chad Campbell	Roxanne Kolder	Signed
543	2021-06-16 12:49	Anonymous (not verified)	174.250.64.145	McCulloch Construction LLC	Limited Liability Company	2590 SE 68TH 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.	2021-04-01	Scott Rouse	MCCULLOCHCONSTRUCTION78@GMAIL.COM	PLEASANT HILL	Polk	IA	Joel Rouse	Shonna Rouse	Signed	(1) The employer does not elect the employers’ liability coverage.	Scott Rouse	MCCULLOCHCONSTRUCTION78@GMAIL.COM	Owner	PLEASANT HILL	Polk	IA	Joel Rouse	Shonna Rouse	Signed
952	2022-03-05 18:23	Anonymous (not verified)	108.59.100.21	Heaven Sent PC LLC	Limited Liability Company	604 Allamakee St, Waukon,IA 52172	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.	2021-04-01	Justin Piggott	heavensentpetcremation@gmail.com	Waukon	Allamakee	Iowa	Kaia Piggott	Jane M Regan	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Piggott	heavensentpetcremation@gmail.com	Member of LLC	Waukon	Allamakee	Iowa	Kaia Piggott	Jane M Regan	Signed
459	2021-04-05 14:24	Anonymous (not verified)	66.188.136.150	Gerald Bosch	Proprietorship	14359 County Rd. G62 Wapello, IA 52653	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.	2021-04-02	Gerald Bosch	kschumacher@tricorinsurance.com	Wapello	Louisa	IA	Russell Masartis	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Gerald Bosch	kschumacher@tricorinsurance.com	Same	Wapello	Louisa	IA	Russell Masartis	Shuree Behr	Signed
457	2021-04-04 17:35	Anonymous (not verified)	104.237.118.236	Lundt Transport, LLC	Limited Liability Company	3322 Y AVE. FAIRBANK, IA 50629	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.	2021-04-04	SAMUEL LUNDT	samuelrl1998@gmail.com	FAIRBANK	Iowa	Iowa	CYNTHIA LUNDT	KATLYN HILL	Signed	(1) The employer does not elect the employers’ liability coverage.	SAMUEL LUNDT	samuelrl1998@gmail.com	SELF	FAIRBANK	FAYETTE	Iowa	CYNTHIA LUNDT	KATLYN HILL	Signed
460	2021-04-05 15:24	Anonymous (not verified)	173.20.169.155	Tim Stiles	Proprietorship	726 Grant St PO box 217 Dexter Iowa 50070	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.	2021-04-04	Tim Stiles	timcolleenstiles@gmail.com	Dexter	Dallas	Iowa	Karen Penton	ERIC TIERNAN	Signed	(1) The employer does not elect the employers’ liability coverage.	Tim Stiles	timcolleenstiles@gmail.com	Same Tim Stiles	Dexter	Dallas	Iowa	Karen Penton	Eric Tiernan	Signed
475	2021-04-13 19:19	Anonymous (not verified)	173.31.147.225	COAST TO COAST MILLWRIGHT LLC	Limited Liability Company	2909 HWY 71 AND 9	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.	2021-04-05	JANIE CANTU	JOEL@WALKERINSURANCEIA.COM	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	JANIE CANTU	janiecantu433@outlook.com	SELF	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed
476	2021-04-13 19:23	Anonymous (not verified)	173.31.147.225	COAST TO COAST MILLWRIGHT LLC	Limited Liability Company	2909 HWY 71 AND 9 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.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-04-05	ADALBERTO CANTU	JOEL@WALKERINSURANCEIA.COM	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	ADALBERTO CANTU	janiecantu433@outlook.com	SELF-MEMBER	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed
487	2021-04-20 11:10	Anonymous (not verified)	207.191.193.167	Chento Construction	Proprietorship	702 Lincoln St. Ainsworth, IA 52201	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.	2021-04-05	Alberto Garcia	chentoconstruction@hotmail.com	Ainsworth	Washington	Iowa	Anthony Johnson	Jessica Lopez	Signed	(1) The employer does not elect the employers’ liability coverage.	Alberto Garcia	chentoconstruction@hotmail.com	Owner	Ainsworth	Washington	Iowa	Anthony Johnson	Jessica Lopez	Signed
461	2021-04-06 08:49	Anonymous (not verified)	209.152.77.101	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln ST., Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-06	Bart Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed	(1) The employer does not elect the employers’ liability coverage.	Bart Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed
462	2021-04-06 08:56	Anonymous (not verified)	209.152.77.101	Bart Fuller & James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln ST., Ruthven,IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-06	James Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	Signed	(1) The employer does not elect the employers’ liability coverage.	James Fuller	goffins@ruthventel.com	Partner	Ruthven	Palo Alto	Iowa	Louise Helmke	Janice Henningsen	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
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
466	2021-04-08 09:58	Anonymous (not verified)	216.81.153.249	Supreme Express Transport LLC	Limited Liability Company	609 Euclid Ave, 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.	2021-04-10	Liana Gil	liana2702@gmail.com	Cherokee	Cherokee	Iowa	Leigh Laven	Jared Brashears	Signed	(1) The employer does not elect the employers’ liability coverage.	Liana Gill	liana2702@gmail.com	Owner	Cherokee	Cherokee	Iowa	Leigh Laven	Jared Brashears	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
468	2021-04-12 14:54	Anonymous (not verified)	173.27.224.230	PCI Turf LLC	Limited Liability Company	1313 N Grant St. Knoxville, IA 50138	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.	2021-04-12	Ryan Trout	rtrout22@yahoo.com	Knoxville	Marion	Iowa	Joseph Durham	Carson Peterson	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Trout	pci.turf@yahoo.com	Self- owner/operator	Knoxville	Marion	Iowa	Joseph Durham	Carson Peterson	Signed
481	2021-04-14 17:15	Anonymous (not verified)	199.66.15.81	K3 Recycling	Limited Liability Company	601 W. 1st 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.	2021-04-14	JUSTIN KAPPELMAN	justin@kappelmanappliance.com	Indianola	Iowa	Iowa	Kristy Kappelman	Charlie Kappelman	Signed	(1) The employer does not elect the employers’ liability coverage.	JUSTIN KAPPELMAN	justin@kappelmanappliance.com	Same person	Indianola	IA	IA	Kristy Kappelman	Charlie Kappelman	Signed
482	2021-04-14 21:21	Anonymous (not verified)	98.17.35.5	K3 Recycling LLC	Limited Liability Company	14801 180th Ave, Milo, IA 50166	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.	2021-04-14	Charles Raymond Kappelman	charliekappelman@yahoo.com	MILO	Warren	United States	Ryan Matthew Kappelman	John Allen Bahr	Signed	(1) The employer does not elect the employers’ liability coverage.	K3 Recycling LLC	charliekappelman@yahoo.com	Co-owner	Milo	Warren	Iowa	Ryan Matthew Kappelman	John Allen Bahr	Signed
483	2021-04-16 10:47	Anonymous (not verified)	204.155.61.217	Joseph Jones DBA Jones Sealcoating and Asphalt Repair	Limited Liability Company	1033 Hummingbird Cir	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.	2021-04-16	Joseph Jones	iscrapcu@yahoo.com	Waterloo	Iowa	Iowa	Kyle Hildman	Dan Sinnott	Signed	(1) The employer does not elect the employers’ liability coverage.	Jospeh Jones	iscrapcu@yahoo.com	OWNER	Waterloo	Black Hawk	IA	Kyle Hildman	Dan Sinnott	Signed
484	2021-04-16 10:58	Anonymous (not verified)	66.188.136.150	Erick Hodges	Proprietorship	3039 Magnolia Dr. Bettendorf, IA 52722	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-16	Erick Hodges	kschumacher@tricorinsurance.com	Bettendorf	Scott	IA	Jordan Bass	Russell Masartis	Signed	(1) The employer does not elect the employers’ liability coverage.	Erick Hodges	kschumacher@tricorinsurance.com	Same	Bettendorf	Scott	IA	Jordan Bass	Russell Masartis	Signed
485	2021-04-16 11:58	Anonymous (not verified)	69.57.23.123	CRAIG AUKES	Proprietorship	43397 50TH AVENUE, BUFFALO CENTER, IA 50424	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.	2021-04-16	CRAIG AUKES	cdaukes@yahoo.com	Buffalo Center	Winnebago	Iowa	Steven Heyer	Cindy Mawdsley	Signed	(1) The employer does not elect the employers’ liability coverage.	CRAIG AUKES	cdaukes@yahoo.com	Employer-Proprietor	Buffalo Center	Winnebago	IA	Steven Heyer	Cindy Mawdsley	Signed
489	2021-04-20 13:47	Anonymous (not verified)	69.63.16.2	Mow-n-Mor Lawn & Landscaping LLC	Limited Liability Company	2585 500th St SW, Kalona, IA 52247	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.	2021-04-19	Robert Sieren	mtesdell@yahoo.com	Kalona	Johnson	Iowa	Scott Freeman	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Sieren	mtesdell@yahoo.com	Managing Member	Kalona	Johnson	Iowa	Scott Freeman	Dyan Kriener	Signed
488	2021-04-20 13:42	Anonymous (not verified)	69.63.16.2	STC Construction LLC	Limited Liability Company	329 Sycamore St, Riverside, IA 52327	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-20	Sean Crane	stc0241@gmail.com	Riverside	Washington	Iowa	Carol Glass	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Sean Crane	stc0241@gmail.com	Managing Member	Riverside	Washingon	Iowa	Carol Glass	Dyan Kriener	Signed
490	2021-04-20 14:06	Anonymous (not verified)	173.18.16.129	frey construction	Limited Liability Company	1388 205th 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.	2021-04-20	Dana Frey	dingaf37@yahoo.com	Creston	Union	Iowa	Lesa Reeves	Kelly Coluzzi	Signed	(1) The employer does not elect the employers’ liability coverage.	Dana Frey	dingaf37@yahoo.com	owner	Creston	Union	Iowa	Lesa Reeves	Kelly Coluzzi	Signed
491	2021-04-20 15:57	Anonymous (not verified)	199.102.210.217	mjm,inc	Proprietorship	32345 200th st dallas centert ia 50063	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.	2021-04-20	john paul wewrner	johnpwerner17@gmail.com	osage	michell	ia	carolyn lee werner	amanda lee johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	johnwerner	johnpwerner17@gmail.com	friend	osage	mithell	ia	carolyn lee werner	amanda lee johnson	Signed
492	2021-04-22 08:33	Anonymous (not verified)	66.188.136.150	Adrian Hackney	Proprietorship	1513 7th St. Boone, IA 50036	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.	2021-04-20	Adrian Hackney	kschumacher@tricorinsurance.com	Boone	Boone	IA	Shuree Behr	Mitch Kemp	Signed	(1) The employer does not elect the employers’ liability coverage.	Adrian Hackney	kschumacher@tricorinsurance.com	Same	Boone	Boone	IA	Shuree Behr	Mitch Kemp	Signed
493	2021-04-22 08:54	Anonymous (not verified)	66.188.136.150	Frank Lantz	Proprietorship	609 Clinton Street, Charles City, IA 50616	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.	2021-04-21	Frank Lentz	kschumacher@tricorinsurance.com	Charles City	Floyd	IA	Shuree Behr	Mitch Kemp	Signed	(1) The employer does not elect the employers’ liability coverage.	Frank Lantz	kschumacher@tricorinsurance.com	Same	Charles City	Floyd	IA	Shuree Behr	Mitch Kemp	Signed
498	2021-04-27 12:54	Anonymous (not verified)	173.31.147.225	TYREL KINKADE DBA: KINKADE CONSTRUCTION	Proprietorship	2289 165TH ST UNIT 10D	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.	2021-04-21	TYREL KINKADE	hogtyd97@yahoo.com	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	TYREL KINKADE	JOEL@WALKERINSURANCEIA.COM	SELF	SPIRIT LAKE	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
494	2021-04-22 12:41	Anonymous (not verified)	173.18.16.129	Unique Drywall Finishing LLC	Limited Liability Company	509 E 26th 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.	2021-04-22	jose angel chavez	uniquewal@yahoo.com	Des Moines	Polk	Iowa	Lesa Reeves	Jen Lambert	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Angel Chavez	uniquewal@yahoo.com	owner	Des Moines	Polk	Iowa	Lesa Reeves	Jen Lambert	Signed
496	2021-04-23 12:48	Anonymous (not verified)	173.29.190.18	A+ Roofing and Siding Co	Proprietorship	1636 15th St Pl, Moline, IL 61265	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.	2021-04-22	SHAWN HICKS	APLUSROOFINGQCA@YAHOO.COM	Milan	IL	United States	deena hicks	Mike Chandler	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	SHAWN HICKS	APLUSROOFINGQCA@YAHOO.COM	SELF/OWNER	Milan	IL	United States	deena hicks	Mike Chandler	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
451	2021-03-25 17:00	Anonymous (not verified)	166.181.80.120	Rogers conc,. const,	Partnership	220804 CO, RD, ANAMOSA IA, 52205	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.	2021-04-25	Alex olah	aolah43@gmail.com	Cedar Rapids	Linn	Iowa	Robin marie kane	Augie rodreguez	Signed	(1) The employer does not elect the employers’ liability coverage.	Kevin johnson	kevinecollins@libertymutual.com	Ins , Agent	Appleton	Dane	Wisconsin	Robin marie kane	Augie Rodriguez	Signed
497	2021-04-27 09:25	Anonymous (not verified)	204.153.176.147	SHANE HUCK	Proprietorship	1070 305TH STREET, NASHUA, IOWA 50658	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.	2021-04-27	SHANE HUCK	WOODHUCK@GMAIL.COM	NASHUA	CHICKASAW	IOWA	KIM LOECKLE	RACHEL SCHNEIDER	Signed	(1) The employer does not elect the employers’ liability coverage.	SHANE HUCK	WOODHUCK@GMAIL.COM	OWNER	NASHUA	CHICKASAW	IOWA	KIM LOECKLE	RACHEL SCHNEIDER	Signed
499	2021-04-28 08:05	Anonymous (not verified)	167.142.98.81	Bents Consulting LLC	Limited Liability Company	2147 160th Street Boone Iowa 50036	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.	2021-04-28	Jeremy D Bents	help@bentsconsulting.com	Boone	Boone	Iowa	Derek Hanson	Bob Clements	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeremy D Bents	help@bentsconsulting.com	Owner	Boone	Boone	Iowa	Derek Hanson	Bob Clements	Signed
500	2021-04-29 13:09	Anonymous (not verified)	204.155.61.217	JWJ Home Remodeling LLC	Limited Liability Company	16915 Weaver Lake Dr, Maple Grove MN 55311	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.	2021-04-29	Jackson Janzen	jacksonjanzen@hailmayday.com	Maple Grove	hennepin	MN	Ashley Kraft	DocuSign	Signed	(1) The employer does not elect the employers’ liability coverage.	Jackson Janzen	jacksonjanzen@hailmayday.com	Owner	Maple Grove	Hennepin	MN	Ashley Kraft	DocuSign	Signed
501	2021-04-29 15:47	Anonymous (not verified)	184.179.6.93	Rodney Bohannon	Proprietorship	5221 Crogans Way Rd, Council Bluffs IA 51501	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.	2021-04-29	Rodney Bohannon	bohannonrod@gmail.com	Council Bluffs	POTTAWATTAMIE	iowa	KIMBERLY L ARFMAN	Tami Cull	Signed	(1) The employer does not elect the employers’ liability coverage.	Rodney Bohannon	bohannonrod@gmail.com	Owner	Council Bluffs	POTTAWATTAMIE	IA	KIMBERLY L ARFMAN	Tami Cull	Signed
1531	2023-03-24 08:40	Anonymous (not verified)	94.188.207.228	Schneiter Insurance and Financial Solutions	Limited Liability Company	900 E 3RD 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.	2021-05-01	Jackie Schneiter	grlschneiter@gmail.com	MONTICELLO	IA	United States	Ronald Schneiter	Reagan Schneiter	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacqueline Schneiter	jackie@we78ins.com	owner	ANAMOSA	JONES	IOWA	RONALD SCHNEITER	REAGAN SCHNEITER	Signed
502	2021-05-04 12:56	Anonymous (not verified)	75.89.78.95	HENNICK TREE SERVICE LLC	Limited Liability Company	1852 MAINE RIDGE ROAD, CENTRAL CITY, IA 52214	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.	2021-05-04	BRANDON ALAN HENNICK	hennicktreeservice@gmail.com	CENTRAL CITY	LINN	IOWA	KATHY RUTH WOOD	ROBBIE WILLIAM WILLIS	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Brandon Hennick	hennicktreeservice@gmail.com	OWNER	CENTRAL CITY	IA	United States	KATHY RUTH WOOD	ROBBIE WILLIAM WILLIS	Signed
515	2021-05-11 15:18	Anonymous (not verified)	66.188.136.150	Odie Mitchell	Proprietorship	10441 Serenity Dr. DeMotte, IN 46310	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.	2021-05-05	Odie Mitchell	kschumacher@tricorinsurance.com	DeMotte	Jasper	IN	Shuree Behr	Jordan Bass	Signed	(1) The employer does not elect the employers’ liability coverage.	Odie Mitchell	kschumacher@tricorinsurance.com	Same	DeMotte	Jasper	IN	Shuree Behr	Jordan Bass	Signed
516	2021-05-12 12:41	Anonymous (not verified)	66.188.136.150	Odie Mitchell	Proprietorship	10441 Serenity Dr. DeMotte, IN 46310	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.	2021-05-05	Odie Mitchell	kschumacher@tricorinsurance.com	DeMotte	Jasper	IN	Shuree Behr	Jordan Bass	Signed	(1) The employer does not elect the employers’ liability coverage.	Odie Mitchell	kschumacher@tricorinsurance.com	Same	DeMotte	Jasper	IN	Shuree Behr	Jordan Bass	Signed
517	2021-05-12 15:08	Anonymous (not verified)	66.188.136.150	Lawrence D Todd Jr.	Proprietorship	540 Sullivan St. Dubuque, IA 52001	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-05	Lawrence D Todd Jr.	kschumacher@tricorinsurance.com	Dubuque	Dubuque	IA	Shuree Behr	Jordan Bass	Signed	(1) The employer does not elect the employers’ liability coverage.	Lawrence D Todd Jr.	kschumacher@tricorinsurance.com	Same	Dubuque	Dubuque	IA	Shuree Behr	Jordan Bass	Signed
504	2021-05-06 15:43	Anonymous (not verified)	75.162.84.34	Erreguin Labra Roofing LLC	Limited Liability Company	642 S Washington Ave Mason City IA 50401	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.	2021-05-06	Hilario Labra Trejo	erreguin06@gmail.com	mason city	cerro gordo	Iowa	Liliana Sanchez	Yolanda Mendoza	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Fernando Erreguin	Erreguin06@gmail.com	member	Mason city	cerro gordo	iowa	Liliana sanchez	yolanda mendoza	Signed
520	2021-05-17 10:32	Anonymous (not verified)	50.82.130.211	Madison Oldenburger	Proprietorship	809 3rd Avenue, Parkersburg, IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-06	Madison Oldenburger	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Madison Oldenburger	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed
525	2021-05-18 09:42	Anonymous (not verified)	50.82.130.211	Adrian Bernard	Proprietorship	803 Russell Circle, Parkersburg IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-07	Adrian Bernard	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Adrian Bernard	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Chad Campbell	Signed
505	2021-05-10 07:06	Anonymous (not verified)	69.63.16.2	Three Boys Contracting LLC	Limited Liability Company	1108 Cullen Dr, Tiffin, IA 52340	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.	2021-05-08	Brandon J Campbell	threeboyscarpentry@gmail.com	Tiffin	Johnson	Iowa	Steve Fishman	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandon J Campbell	threeboyscarpentry@gmail.com	Managing Member	Tiffin	Johnson	Iowa	Steve Fishman	Dyan Kriener	Signed
518	2021-05-12 19:22	Anonymous (not verified)	184.105.50.148	Angela Smith and Christopher Smith	Proprietorship	2321 130th Street Belmond, IA 50421	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-08	Christopher Lynn Smith	1angismith@gmail.com	Belmond	Wright	Iowa	Betty Warrington	Nicholas Mehmen	Signed	(1) The employer does not elect the employers’ liability coverage.	Angela Kay Smith	1angismith@gmail.com	Wife	Belmond	Wright	Iowa	Betty Warrington	Nicholas Mehmen	Signed
506	2021-05-10 09:29	Anonymous (not verified)	199.102.211.129	Nathan J Hurst LLC DBA J&K Construction	Limited Liability Company	3598 Orchard Rd. Osage, IA 50461	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	Nathan J Hurst	jkconstructionjake@yahoo.com	Osage	Mitchell	Iowa	Breanna Fox	Karl Herman	Signed	(1) The employer does not elect the employers’ liability coverage.	Breanna Fox	jkconstructionjake@yahoo.com	Office Manager	Osage	Mithell	Iowa	Nathan J Hurst	Karl F Herman	Signed
507	2021-05-10 10:20	Anonymous (not verified)	192.30.186.37	Stowe's Drywall	Proprietorship	PO Box 712, Ponca, NE 68776	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	Danny Stowe	deb.nana.stowe@gmail.com	Ponca	Dixon	NE	Katie Jenks	Virginia Anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Danny Stowe	deb.nana.stowe@gmail.com	Owner	Ponca	Dixon	NE	Katie Jenks	Virginia Anderson	Signed

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