Nonelection of Workers' Compensation or Employers' Liability Coverage

Primary tabs

Secondary tabs

Showing 551 - 600 of 2227. Show 10 | 50 | 100 | 200 | 500 | 1000 | All results per page.

#	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:
266	2020-09-21 18:08	Anonymous (not verified)	174.126.94.77	Club Fantasy Inc.	Limited Liability Company	P.O. Box 5115 Sioux City Iowa 51102	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-21	Curtis A. Behr	cacbehr@aol.com	Sioux City	Woodbury	Iowa	Carter Vahle	Dawn Meyer	Signed	(1) The employer does not elect the employers’ liability coverage.	Curtis A. Behr	cacbehr@aol.com	Self	Sioux City	Woodbury	Iowa	Carter Vahle	Dawn Meyer	Signed
176	2020-06-07 08:23	Anonymous (not verified)	174.16.51.128	TrueFood LLC	Limited Liability Company	2055 Nature Ave Stanton IA 51573	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-24	Brian Barkman	brian.barkman@truefood.farm	Georgetown	Williamson	Texas	Wanda Barkman	Chelsea Church	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Barkman	brian.barkman@truefood.farm	TrueFood LLC is owned by agent	Stanton	Montgomery	IA	Wanda Barkman	Chelsea Church	Signed
1008	2022-03-25 15:15	Anonymous (not verified)	174.192.130.230	Hill's Rehab &Landscape L.L.C	Limited Liability Company	3717 15th ave Moline Illinois 61365	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-25	Joshua hill	joshuajameshill79@gmail.com	Moline	Rock Island	Illinois	Lindsay erin Hill	NICOLE ann lear	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua james hill	joshuajameshill79@gmail.com	President	Moline	Rock Island	Illinois	Lindsay Erin Hill	NIcole ann lear	Signed
954	2022-03-08 11:07	Anonymous (not verified)	174.192.138.191	Duwa Waterproofing	Limited Liability Company	729 Deer View 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.	2022-03-08	Stacy Duwa	duwawaterproofing@gmail.com	Tiffin	Johnson	Iowa	Chad Cooper	Curtis Sexton	Signed	(1) The employer does not elect the employers’ liability coverage.	Stacy Duwa	duwawaterproofing@gmail.com	President	Tiffin	Johnson	Iowa	Chad Cooper	Curtis Sexton	Signed
992	2022-03-21 19:42	Anonymous (not verified)	174.192.66.11	Christopher Binns	Proprietorship	1324 Grand Ave, Davenport, IA 52803	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-21	Christopher Binns	christophersbinns@gmail.com	Davenport	Scott	IA	Adam Coleman	Rose Snyder	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher Binns	christophersbinns@gmail.com	same	Davenport	Scott	IA	Adam Coleman	Rose Snyder	Signed
323	2020-11-19 10:55	Anonymous (not verified)	174.192.67.61	Connor trucking	Proprietorship	2791 270th st Dewitt ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-11-19	Richard Todd Connor	connortrucking@hotmail.com	Dewitt	Clinton	Iowa	Michelle Connor	Josh connor	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard Todd Connor	connortruckin@hotmail.com	Self	Dewitt	Clinton	Iowa	Michelle Connor	Josh Connor	Signed
1267	2022-08-17 14:11	Anonymous (not verified)	174.192.75.162	Elijah wyant	Proprietorship	708 1/2 w 3rd st davenport ia 52802	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-17	Elijah wyant	Aidenwyant@gmail.com	Davenport	Scott	Iowa	Jake laxton	Courtney sanders	Signed	(1) The employer does not elect the employers’ liability coverage.	Elijah wyant	Aidenwyant@gmail.com	Self	Davenport	Scott	Iowa	Jake laxton	Courtney sanders	Signed
990	2022-03-21 15:18	Anonymous (not verified)	174.192.80.32	Chris Binns	Proprietorship	1324 Grand Ave Davenport, IA 52803	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-21	Christ Binns	christophersbinns@gmail.com	Davenpory	Scott	IA	Adam Coleman	Rose Snyder	Signed	(1) The employer does not elect the employers’ liability coverage.	Chris Binns	christophersbinns@gmail.com	Same	Davenport	Scott	IA	Adam Coleman	Rose Snyder	Signed
1333	2022-10-13 14:01	Anonymous (not verified)	174.192.85.141	Terry Smith	Proprietorship	1028 14th Avenue Fulton il	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-14	Terry Smith	terry1270smith@gmail.com	Fulton	IL	United States	Angela Smith	Tracey Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Terry Smith	terry1270smith@gmail.com	Wife	Fulton	IL	United States	Angie Smith	Tracey smith	Signed
820	2022-01-03 10:41	Anonymous (not verified)	174.195.193.112	Wolverine Construction LLC	Limited Liability Company	467 s 84th 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.	2022-01-03	steffan sheehey	steffanrobert@gmail.com	West Des Moines	Dallas	IA	Christopher Sheehey	Taylor Lyman	Signed	(1) The employer does not elect the employers’ liability coverage.	steffan sheehey	steffanrobert@gmail.com	Manager	West Des Moines	Dallas	IA	Christopher Sheehey	Marcus Hatcher	Signed
1028	2022-04-02 11:01	Anonymous (not verified)	174.198.64.100	Great-Dain Htg/Ac & Plumbing	Proprietorship	1616 Maple Rd. Harlan, Iowa 51537	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-02	Richard Nee	great-dain@hotmail.com	Harlan	Shelby	Iowa	Doug Clark	Jesse Nee	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard Nee	great-dain@hotmail.com	Self	Harlan	Shelby	Iowa	Doug Clark	Jesse Nee	Signed
1396	2022-12-19 18:35	Anonymous (not verified)	174.198.65.20	Flyover Productions LLC	Limited Liability Company	300 S Clinton St.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-19	Richard A Redfern	richredfern3@gmail.com	Iowa City	IA	United States	Susan Redfern	Aditi Reddy	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard Redfern	richredfern3@gmail.com	Owner of company	Iowa City	Iowa	United States	Susan Redfern	Aditi Reddy	Signed
1302	2022-09-11 22:05	Anonymous (not verified)	174.198.65.241	Bruce g Sellner	Proprietorship	40998 597th ave new ulm mn 56073	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-11	Bruce g Sellner	bgsellner74@gmail.com	New ulm	Nicollet	Minnesota	Carol m aura	Steve l griebel	Signed	(1) The employer does not elect the employers’ liability coverage.	Bruce g Sellner	bgsellner74@gmail.com	Owner	New ulm	Nicollet	Mn	Carol m aura	Steve l griebel	Signed
1303	2022-09-11 22:05	Anonymous (not verified)	174.198.65.241	Bruce g Sellner	Proprietorship	40998 597th ave new ulm mn 56073	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-11	Bruce g Sellner	bgsellner74@gmail.com	New ulm	Nicollet	Minnesota	Carol m aura	Steve l griebel	Signed	(1) The employer does not elect the employers’ liability coverage.	Bruce g Sellner	bgsellner74@gmail.com	Owner	New ulm	Nicollet	Mn	Carol m aura	Steve l griebel	Signed
1304	2022-09-11 22:05	Anonymous (not verified)	174.198.65.241	Bruce g Sellner	Proprietorship	40998 597th ave new ulm mn 56073	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-11	Bruce g Sellner	bgsellner74@gmail.com	New ulm	Nicollet	Minnesota	Carol m aura	Steve l griebel	Signed	(1) The employer does not elect the employers’ liability coverage.	Bruce g Sellner	bgsellner74@gmail.com	Owner	New ulm	Nicollet	Mn	Carol m aura	Steve l griebel	Signed
727	2021-11-05 14:46	Anonymous (not verified)	174.198.66.202	Bret Swift Swift Enterprises	Proprietorship	2240 Coldstream Drive 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.	2020-01-13	Brett Swidt	swiftenterprises@me.com	Cedar Rapids	Linn	Iowa	Sarah Coberley	Heather Howell	Signed	(1) The employer does not elect the employers’ liability coverage.	Bret Swift	swiftenterprises@me.com	Self Employed	Cedar Rapids	Linn	Iowa	Sarah Coberley	Heather Howell	Signed
725	2021-11-05 14:32	Anonymous (not verified)	174.198.66.202	Jay Schulte	Proprietorship	7530 Prairie Hawk Dr Sw, Cedar Rapids, Ia 52404	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-15	Jay Schulte	schultejay@Hotmail.com	Cedar Rapids	Linn	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Jay Schulte	schultejay@hotmail.com	Self Employed	Cedar Rapids	Linn	Ia	Sarah Coberley	Heather Howell	Signed
719	2021-11-05 13:48	Anonymous (not verified)	174.198.66.202	James Johnson Ace Floor Guys	Proprietorship	521 29th st 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.	2020-08-13	James Johnson	acefloorguysia@gmail.com	Cedar Rapids	Linn	Iowa	Sarah Coberley	Heather Howell	Signed	(1) The employer does not elect the employers’ liability coverage.	James Johnson	acefloorguysia@gmail.com	Self Employed	Cedar Rapids	Linn	Iowa	Heather Howell	Sarah Coberley	Signed
726	2021-11-05 14:39	Anonymous (not verified)	174.198.66.202	John Stoltzfus JM Tile LLC	Limited Liability Company	Wellman, Ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-19	John Stoltzfus	installation@bachmeiercarpetone.com	Wellman	Washington	Iowa	Sarah Coberley	Heather Howell	Signed	(1) The employer does not elect the employers’ liability coverage.	John Stoltzfus	installation@bachmeiercarpetone.com	Self	Wellman	Washington	Iowa	Sarah Coberley	Heather Howell	Signed
700	2021-10-29 11:04	Anonymous (not verified)	174.198.66.50	T&C Lawn Care LLC	Limited Liability Partnership	1827 Black Hawk St Waterloo IA 50702	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-29	Cody R Woodley	cody.woodley50@gmail.com	Cedar Falls	Blackhawk	Iowa	Tara R Woodley	Sara Woodley	Signed	(1) The employer does not elect the employers’ liability coverage.	Kristi S. Demuth Agency, Inc.	kdemuth@amfam.com	Client	Waverly	Bremer	Iowa	Cody R Woodley	Tyler M Croft	Signed
1139	2022-06-02 08:49	Anonymous (not verified)	174.198.67.34	Gentry Hardware Incorporated	Partnership	308 5th Street; Rockwell City, IA 50579	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-02	Emily Gentry	emilygentry1127@gmail.com	Rockwell City	Calhoun	IA	Ben Rand	Karie Knouf	Signed	(1) The employer does not elect the employers’ liability coverage.	Emily Gentry	emilygentry1127@gmail.com	Owner	Rockwell City	Calhoun	IA	Ben Rand	Karie Knouf	Signed
1195	2022-07-08 13:24	Anonymous (not verified)	174.198.67.66	Chapas Construction	Limited Liability Company	6424 Roseland 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.	2022-07-08	Polibio Raul Chapa Farez	chapasconstructionllc@gmail.com	Urbandale	IA	IA	Brenda Rivas	Charlie Chapa	Signed	(1) The employer does not elect the employers’ liability coverage.	Polibio Raul Chapa	chapasconstructionllc@gmail.com	President	Urbandale	IA	IA	Brenda Rivas	Charlie Chapa	Signed
650	2021-09-22 20:46	Anonymous (not verified)	174.198.68.116	Freedom field services	Limited Liability Company	6285 n 67 ave w baxter iowa 50028	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-22	joseph robert cunningham jr	joecunningham1966@protonmail.com	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed	(1) The employer does not elect the employers’ liability coverage.	joseph robert cunningham jr	joecunningham1966@protonmail.com	owner	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed
651	2021-09-22 21:05	Anonymous (not verified)	174.198.68.116	Freedom field services LLC	Limited Liability Company	6285 n 67 ave w. BAXTER IOWA 50028	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-22	joseph robert cunningham jr	joecunningham1966@protonmail.com	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed	(1) The employer does not elect the employers’ liability coverage.	joseph robert cunningham jr	joecunningham1966@protonmail.com	owner	Baxter	IA	United States	chelsey a cunningham	jordan r cunningham	Signed
1300	2022-09-07 16:38	Anonymous (not verified)	174.198.70.216	Phillip Phelps	Proprietorship	2900 4th St Marion, IA 52302	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-07	Phillip Phelps	phillipphelps8732@yahoo.com	Marion	Linn	Iowa	Kaitlin Davidson	Kevin Phelps	Signed	(1) The employer does not elect the employers’ liability coverage.	Phillip Phelps	phillipphelps8732@yahoo.com	Self	Marion	Linn	Iowa	Kaitlin Davidson	Kevin Phelps	Signed
1070	2022-04-26 09:35	Anonymous (not verified)	174.198.72.171	Boyz Roofing LLC	Limited Liability Company	802 E County Lane Rd Lot 25	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-26	Cupertino Rodriguez Hernandez	christopherrodriguez091889@gmail.com	Des Moines	Polk	Iowa	Yoselin Morales	Manny Sokop	Signed	(1) The employer does not elect the employers’ liability coverage.	Cupertino Rodriguez Hernandez	christopherrodriguez091889@gmail.com	Owner	Des Moines	Polk	Iowa	Yoselin Morales	Manny Sokop	Signed
1069	2022-04-26 08:39	Anonymous (not verified)	174.198.72.171	GR Roofing	Proprietorship	802 E County Line Rd Lot 137, Des Moines, Ia 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-26	Eleazar Guzman-Rios	emmanuelgscop.1425@gmail.com	Des Moines	Polk	Iowa	Manny Socop	Julio Andrew	Signed	(1) The employer does not elect the employers’ liability coverage.	Eleazar Guzman-Rios	emmanuelgscop.1425@gmail.com	Owner	Des Moines	Polk	Iowa	Manny Socop	Julio Andrews	Signed
446	2021-03-23 12:39	Anonymous (not verified)	174.198.72.209	Final Finish llc	Limited Liability Company	3824 12th st Des Moines Iowa 50313	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-23	Wesley Robert Detman	wesdet@gmail.com	Drs Moines	Polk	Iowa	Leah Laxton	Lucas Laxton	Signed	(1) The employer does not elect the employers’ liability coverage.	Wesley Robert Detman	wesdet@gmail.com	Owner	Des Moines	Polk	Iowa	Leah Laxton	Lucas Laxton	Signed
449	2021-03-25 10:53	Anonymous (not verified)	174.198.73.94	A&F Painting llc	Limited Liability Company	411 E Dunham 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.	2021-03-25	Miguel Afanador Olguin	mafanador02@gmail.com	Des Moines	Polk	Iowa	Alfonzo Afanador	Noemi Afanador	Signed	(1) The employer does not elect the employers’ liability coverage.	Miguel Afanador Olguin	mafanador02@gmail.com	Owner	Des Moines	Polk	Iowa	Alfonzo Alfanador	Noemi Alfanador	Signed
1427	2023-01-23 10:53	Anonymous (not verified)	174.198.74.123	Landon Manfull	Proprietorship	51909 hwy 210	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.	2023-01-01	Landon Manfull	landonmanfull1@gmail.com	Slater	Story	Iowa	Landon Manfull	Landon Manfull	Signed	(1) The employer does not elect the employers’ liability coverage.	Landon Manfull	landonmanfull1@gmail.com	Myself	Slater	Story	Iowa	Landon Manfull	Landon Manfull	Signed
929	2022-02-18 09:18	Anonymous (not verified)	174.198.74.217	LA Painting LLC	Limited Liability Company	6460 Merle Hay Rd unit 222 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.	2022-02-18	Adolfo Rodriguez Afanador	adolforodriguez11@yahoo.com	Johnston	Polk	Iowa	Esequiel Rodriguez	Karina Valdez	Signed	(1) The employer does not elect the employers’ liability coverage.	Adolfo Rodriguez Afanador	adolforodriguez11@yahoo.com	Owner	Johnston	Polk	Iowa	Esequiel Rodriguez	Karina Valdez	Signed
414	2021-02-28 15:32	Anonymous (not verified)	174.198.75.211	Charlie Christian Hutt	Proprietorship	609 E. main St.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-29	Charlie Christian Hutt	bmxican_04@hotmail.com	Brooklyn	poweshiek	IA	gene shafbough	hannah hutt	Signed	(1) The employer does not elect the employers’ liability coverage.	Charlie Christian Hutt	bmxican_04@hotmail.com	sole	Brooklyn	poweshiek	IA	gene shafbough	hannah hutt	Signed
785	2021-12-09 09:15	Anonymous (not verified)	174.198.75.71	Daniel Vega camacho	Proprietorship	2415 river ,meadows drive Des Moines Iowa 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-09	Daniel Vega camacho	dvega50265@gmail.com	Des Moines	Polk	Iowa	Chad Smith	Adam Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Vega camacho	dvega50265@gmail.com	Self	Des Moines	Polk	Iowa	Chad Smith	Adam Smith	Signed
623	2021-08-30 15:03	Anonymous (not verified)	174.198.77.231	Joe Dawson	Proprietorship	1088, Dogwood Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-30	Joe R Dawson	joerdawson@gmail.com	Coon Rapids	IA	United States	Linda Doran	Megan Specht	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Joe R Dawson	joerdawson@gmail.com	Owner	Coon Rapids	IA	United States	Linda Doran	Megan Specht	Signed
930	2022-02-20 13:24	Anonymous (not verified)	174.198.77.72	2Maros Excavating Company	Limited Liability Company	204 West First Street, Saint Donatus, Iowa 52071	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-20	Steve Maro	2marosmfg@gmail.com	Saint Donatus	Jackson	Iowa	Brenda McKenna	Joe McKenna	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Maro	2marosmfg@gmail.com	Owner	Saint Donatus	Jackson	Iowa	Brenda McKenna	Joe McKenna	Signed
313	2020-11-11 20:35	Anonymous (not verified)	174.198.78.148	Wilson Snow Maintenance	Proprietorship	3518 183rd Avenue, Carlisle, Iowa 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.	2020-11-11	Bruce E. Wilson	bewilson83@gmail.com	Carlisle	Warren	Iowa	Kristen Wilson	Garett Wilson	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Bruce Wilson	bewilson83@gmail.com	self	Carlisle	Warren	Iowa	Kristen Wilson	Garett Wilson	Signed
404	2021-02-16 13:30	Anonymous (not verified)	174.198.79.179	Topline Painting llc	Limited Liability Company	1603 e 32nd st Des Moines IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-16	Michael nunez	toplinepaintingiowa@gmail.com	Des Moines	Polk	Iowa	Jimmy nunez	Jose Nunez	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael nunez	toplinepaintingiowa@gmail.com	Owner	Des moines	Polk	Iowa	Jimmy nunez	Jose nunez	Signed
862	2022-01-27 12:02	Anonymous (not verified)	174.198.81.166	Big Bear Construction,LLC	Limited Liability Company	4508 Hiawatha Ave 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.	2022-01-27	Michael Allen Becker	mike4bbc@gmail.com	Cedar Rapids	Linn	Iowa	Kenny McCracken	Corey Becker	Signed	(1) The employer does not elect the employers’ liability coverage.	Kevin Paul Becker jr	kbeckerbbc@gmail.com	Brother/partner	Cedar Rapids	Linn	Iowa	Kenny McCracken	Corey Becker	Signed
863	2022-01-27 12:13	Anonymous (not verified)	174.198.81.166	Big Bear Construction llc	Limited Liability Company	4508 Hiawatha Ave ne Cedar Rapids iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-27	Kevin Paul Becker jr	kbeckerbbc@gmail.com	Cedar Rapids	Linn	Iowa	Kenny McCracken	Corey Becker	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Allen Becker	mike4bbc@gmail.com	Brother/Partner	Cedar Rapids	Linn	Iowa	Kenny McCracken	Corey Becker	Signed
325	2020-11-23 11:14	Anonymous (not verified)	174.198.82.169	Dan davidson	Limited Liability Company	21Lincoln Dr	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.	2020-11-22	Daniel Lee davidson	unitedremodelingdd@gmail.com	Palo	Linn	IA	Daniel Lee davidson	Daniel Lee davidson	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Daniel Lee davidson	unitedremodelingdd@gmail.com	Owner	Palo	Linn	IA	Daniel Lee davidson	Daniel Lee davidson	Signed
774	2021-11-29 12:28	Anonymous (not verified)	174.198.82.208	Demetrio's Construction	Proprietorship	2018 Heights Ave Sioux City, IA 51104	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-29	Guillermo Demetrio	moralesdalia44@yahoo.com	Sioux City	Woodbury	Iowa	Dalia E. Morales Galvez	Vanessa Topete	Signed	(1) The employer does not elect the employers’ liability coverage.	Guillermo Demetrio	moralesdalia44@yahoo.com	Owner	Sioux City	Woodbury	Iowa	Dalia Morales Galvez	Vanessa Topete	Signed
328	2020-11-26 12:28	Anonymous (not verified)	174.198.82.38	Duke millwright doing business as duke & sons	Limited Liability Company	3264 e Payton ave Des Moines iowa 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2020-11-26	Jeremiah duke	jpduke24.7.365@gmail.com	Des Moines	Polk county	Iowa	Daniel Patrick Hemann	Nikki Marie Harvey	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Diana duke	dukemillwright@gmail.com	Self	Des Moines	Polk	Iowa	Nikki Marie Harvey	Daniel Patrick Hemann	Signed
1101	2022-05-13 12:55	Anonymous (not verified)	174.199.102.54	Daniel Blanco	Proprietorship	1403 2nd Ave S	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-13	Daniel Blanco	chindan77@yahoo.com	Ft Dodge	Webster	IA	Vanessa Blanco	Elva Castañeda	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Blanco	chindan77@yahoo.com	Self	Ft Dodge	Webster	IA	Vanessa Blanco	Elva Castañeda	Signed
1064	2022-04-21 12:48	Anonymous (not verified)	174.199.77.87	Hocken Construction LLC	Limited Liability Company	926 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.	2021-01-01	Ryan Hocken	ryan.hocken@yahoo.com	Osage	Mitchell	Iowa	Melissa Hocken	Tyler Schwarck	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Hocken	ryan.hocken@yahoo.com	Owner	Osage	Mitchell	Iowa	Melissa Hocken	Tyler Schwarck	Signed
970	2022-03-14 14:08	Anonymous (not verified)	174.199.79.176	Friends Transportation Services LLC	Limited Liability Company	6010 Creston Ave Unit 26, Des Moines, IA 50321	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-14	Mohammed Dood	mohedali777@hotmail.com	Des Moines	Polk	Iowa	Leigh Laven	Geoff Matlock	Signed	(1) The employer does not elect the employers’ liability coverage.	Mohammed Dood	mohedali777@hotmail.com	Owner	Des Moines	Polk	Iowa	Leigh Laven	Geoff Matlock	Signed
816	2021-12-30 09:56	Anonymous (not verified)	174.199.83.133	Michael Fales	Proprietorship	1987 180th Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-30	Michael Lee Fales	Chubby__69@hotmail.com	Canby	Yellow Medicine	Minnesota	Tori Fales	Jean Fales	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Lee Fales	Chubby__69@hotmail.com	Owner	Canby	Yellow Medicine	Minnesota	Tori Fales	Jean Fales	Signed
1212	2022-07-19 10:15	Anonymous (not verified)	174.209.40.210	James holmes	Proprietorship	866 40th Ave 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.	2022-07-19	James holmes	jrholmes1958@gmail.com	Moline	Rock island	Il	Tiffani branham	Cody dunbar	Signed	(1) The employer does not elect the employers’ liability coverage.	Leaffilter north llc	cdunbar@leaffilter.com	Install manager	Bettendorf	Scott	Ia	Cody dunbar	Tiffani branham	Signed
1128	2022-05-26 11:11	Anonymous (not verified)	174.213.144.187	Leaf Filter	Limited Liability Company	3060 se grimes blvd suite 100-300 Grimes iowa 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-24	Jason charlet	jasonstreeservice2014@gmail.com	Minburn	Dallas	Iowa	Kami lillibridge	Dale charlet	Signed	(1) The employer does not elect the employers’ liability coverage.	N/a	jasoncharlet703@gmail.com	N/a	N/a	N/a	N/a	N/a	N/a	Signed
1154	2022-06-14 00:27	Anonymous (not verified)	174.213.144.227	Arben Bahtirovic	Partnership	3060 South East Grimes Blvd, Suite 100-300 Grimes, Iowa 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-06-14	Arben Bahtirovic	arben2002@gmail.com	West Des Moines	Polk	IOWA	Senida bahtirovic	Mario mandic	Signed	(1) The employer does not elect the employers’ liability coverage.	Arben Bahtirovic	arben2002@gmail.com	Contractor	West Des Moines	Polk	IOWA	Senida bahtirovic	Marijo mandic	Signed
1370	2022-11-13 19:49	Anonymous (not verified)	174.213.144.30	Iowa’s Gutter Specialist	Limited Liability Company	1390 Lark 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.	2022-10-21	Dustin Halverson	dh42312695@gmail.com	Hampton	IA	United States	Patricia Reynolds	Heather Halverson	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin Halverson	dh42312695@gmail.com	Owner	Hampton	IA	United States	Patricia Marie Reynolds	Heather Marie Halverson	Signed

« first
‹ previous
…
8
9
10
11
12
13
14
15
16
…
next ›
last »