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:
558	2021-07-07 13:35	Anonymous (not verified)	66.188.136.150	Austin Kalfus Sr.	Proprietorship	1203 Poppy Ave. Pensacola, FL 32507	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-07	Austin Kalfus Sr.	kschumacher@tricorinsurance.com	Pensacola	Escambia	FL	Mitch Kemp	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Austin Kalfus Sr.	kschumacher@tricorinsurance.com	Same	Pensacola	Escambia	FL	Mitch Kemp	Shuree Behr	Signed
559	2021-07-08 08:27	Anonymous (not verified)	66.188.136.150	Justin Keplinger	Proprietorship	8671 Hamby Rd. Morris, AL 35116	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-07	Justin Keplinger	kschumacher@tricorinsurance.com	Morris	Jefferson	AL	Mitch Kemp	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Keplinger	kschumacher@tricorinsurance.com	Same	Morris	Jefferson	AL	Mitch Kemp	Shuree Behr	Signed
560	2021-07-08 08:46	Anonymous (not verified)	66.188.136.150	Darius Harvey	Proprietorship	2738 E 53rd. Apt. 7 Davenport, IA 52807	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-07	Darius Harvey	kschumacher@tricorinsurance.com	Davenport	Scott	IA	Mitch Kemp	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Darius Harvey	kschumacher@tricorinsurance.com	Same	Davenport	Scott	IA	Mitch Kemp	Shuree Behr	Signed
561	2021-07-08 09:11	Anonymous (not verified)	66.188.136.150	Aaron Maldonado dba ATM Trucking	Proprietorship	1011 Reynolds Drive, Charleston, IL 61920	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-07	Aaron Maldonado dba ATM Trucking	kschumacher@tricorinsurance.com	Charleston	Coles	IL	Mitch Kemp	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Aaron Maldonado dba ATM Trucking	kschumacher@tricorinsurance.com	Same	Charleston	Coles	IL	Mitch Kemp	Shuree Behr	Signed
562	2021-07-08 09:46	Anonymous (not verified)	66.188.136.150	Rick Davis	Proprietorship	521 N 13th St. Salina, KS 67401	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-07	Rick Davis	kschumacher@tricorinsurance.com	Salina	Saline	KS	Mitch Kemp	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Davis	kschumacher@tricorinsurance.com	Same	Salina	Saline	KS	Mitch Kemp	Shuree Behr	Signed
563	2021-07-08 12:16	Anonymous (not verified)	173.17.250.209	Forest Avenue Outreach	Limited Liability Company	1600 6th Ave DSM IA 50314	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-08	Maya Bromolson	maya@goodvibesmovement.org	Des Moines	IA	United States	Joel Donaghy	Brian Donaghy	Signed	(1) The employer does not elect the employers’ liability coverage.	Maya Bromolson	maya@goodvibesmovement.org	Executive Director	Des Moines	IA	United States	Joel Donaghy	Brian Donaghy	Signed
564	2021-07-08 13:33	Anonymous (not verified)	173.31.156.49	SS Docks	Limited Liability Company	P.O. Box 561 Okoboji IA 51355-0561	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.	2021-07-08	Jason Andrew Snow	snowjas75@gmail.com	Lake Park	Dickinson	IA	Amber Egesdal	Vickie Walters	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	SS Docks	snowjas75@gmail.com	Owner	Okoboji	Dickinson	IA	Amber Egesdal	Vickie Walters	Signed
565	2021-07-08 13:42	Anonymous (not verified)	173.25.132.255	Communications Construction Services LLC	Limited Liability Company	1315 East 38th Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-08	John McCann Jr	communicationconstructionllc@gmail.com	Des Moines	IA	United States	Laura McCann	David Garza	Signed	(1) The employer does not elect the employers’ liability coverage.	Laura McCann	communicationconstructionllc@gmail.com	spouse	Des Moines	IA	United States	John J McCann Jr	David Christopher Garza III	Signed
569	2021-07-09 12:18	Anonymous (not verified)	173.17.250.209	Forest Ave Outreach dba Good Vibes Movement	Limited Liability Company	1600 6th Ave DSM IA 50314	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-09	Ben Spellman	ben@goodvibesmovement.org	Des Moines	IA	United States	Joel Donaghy	Brian Donaghy	Signed	(1) The employer does not elect the employers’ liability coverage.	Maya Bromolson	maya@goodvibesmovement.org	Executive Director	Des Moines	IA	United States	Joel Donaghy	Brian Donaghy	Signed
575	2021-07-14 14:01	Anonymous (not verified)	69.57.205.10	Robert W. Cantrell	Proprietorship	845 East Redwood Circle, Hanford, CA 93230	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-10	Robert Wescott Cantrell	rcr4@comcast.net	Hanford	Kings	CA	Shirley J. Loney	Joel L. Meyer	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Westcott Cantrell	rcr4@comcast.net	proprietor	Hanford	Kings	CA	Shirley J. Loney	Joel L. Meyer	Signed
571	2021-07-12 09:51	Anonymous (not verified)	67.55.237.31	Steve Vogel	Proprietorship	314 NE 2ND ST. Panora, Iowa 50216-2020	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-12	Steve Vogel	thevogels@netins.net	PANORA	Guthrie	United States	Diana Vogel	Adam Vogel	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Vogel	thevogels@netins.net	Self	PANORA	Guthrie	Iowa	Diana Vogel	Adam Vogel	Signed
572	2021-07-13 09:59	Anonymous (not verified)	173.27.17.202	David Lochner	Proprietorship	866 40th ave Bettendorf Iowa 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.	2021-07-13	David Lochner	jnagel@leafhome.com	Dubuque	Dubuque	Iowa	Jacob Nagel	Shawn Cowell	Signed	(1) The employer does not elect the employers’ liability coverage.	David Lochner	jnagel@leafhome.com	Self	Dubuque	Dubuque	Iowa	Jacob Nagel	Shawn Cowell	Signed
573	2021-07-14 09:12	Anonymous (not verified)	166.181.83.201	Dustin Demoss	Proprietorship	407 mechanic 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.	2021-07-13	Dustin Michael DeMoss	dustindemoss14@gmail.com	Monmouth	Iowa	United States	Jake	Jake	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin Michael DeMoss	dustindemoss14@gmail.com	Idk	Monmouth	Iowa	United States	Jake	Jake	Signed
574	2021-07-14 10:43	Anonymous (not verified)	173.27.17.202	Maxwell Taylor	Proprietorship	618 east Colorado St. Davenport Iowa 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.	2021-07-14	Maxwell Taylor	maxwelltaylor33@icloud.com	Davenport	Scott	Iowa	Jacob Nagel	Ty Reindl	Signed	(1) The employer does not elect the employers’ liability coverage.	Maxwell Taylor	maxwelltaylor33@icloud.com	Self	Davenport	Scott	Iowa	Jacob Nagel	Ty Reindl	Signed
576	2021-07-14 18:13	Anonymous (not verified)	69.169.10.40	J&M Excavation Inc.	Limited Liability Company	411 Pine 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.	2021-07-14	Bruce Bilyeu	jmexcavation@outlook.com	Norwalk	Warren	IA	Mike Petersen	Dennis Bilyeu	Signed	(1) The employer does not elect the employers’ liability coverage.	Bruce Bilyeu	jmexcavation@outlook.com	Owner	Norwalk	Warren	IA	Mike Petersen	Dennis Bilyeu	Signed
577	2021-07-16 13:45	Anonymous (not verified)	204.155.61.217	Chris & Michele Burke dba Studio Dance	Proprietorship	3907 Center Point Rd NE, Cedar Rapids, IA 52402	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-07-16	Michele Burke	michele@studiodanceia.com	Marion	Linn	Iowa	Molly Feldman	Sharon Naber	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Michele Burke	michele@studiodanceia.com	owner	Marion	Linn	Iowa	Molly Feldman	Sharon Naber	Signed
578	2021-07-16 15:26	Anonymous (not verified)	184.80.177.137	Scotty's Appliance & TV, LLC	Limited Liability Company	529 5th St NW - Dyersville, IA 52040	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-16	Sandra Krogman	jheims@english-insurance.com	Dyersville	Dubuque	Iowa	Joyce Heims	Derrick Parsons	Signed	(1) The employer does not elect the employers’ liability coverage.	Derrick Parsons	jheims@english-insurance.com	agent	Dyersville	Dubuque	Iowa	Joyce Heims	Derrick Parsons	Signed
1749	2023-07-17 10:52	Anonymous (not verified)	94.188.205.175	Zenon Loreto	Proprietorship	1324 E 29th St Des Moines, IOwa 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.	2021-07-17	Zenon Loreto	deb@piciowa.com	Des Moines	Polk	Iowa	Inspro in 2019	Inspro in 2019	Signed	(1) The employer does not elect the employers’ liability coverage.	Zenon Loreto	deb@piciowa.com	self	Des Moines	Polk	Iowa	Inspro in 2019	Inspro in 2019	Signed
579	2021-07-20 12:37	Anonymous (not verified)	166.205.124.133	M&M HOME IMPROVEMENT	Limited Liability Company	5406 28th Ave. 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.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-07-20	Jarred Alexander	bookkyddjay@gmail.com	Moline	USA	IL	Jacob Nagel	Jacob Nagel	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jarred Alexander	bookkyddjay@gmail.com	Same	Moline	USA	IL	Jacob Nagel	Jacob Nagel	Signed
580	2021-07-22 10:40	Anonymous (not verified)	72.13.27.253	Gudenkauf Tiling & Excavating LLC	Limited Liability Company	1840 275th St Manchester, IA 52057	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-22	Terry Thomas Gudenkauf	tlgudenkauf@yousq.net	Manchester	Delaware	IA	Lisa Gudenkauf	Brandon Mather	Signed	(1) The employer does not elect the employers’ liability coverage.	Terry Gudenkauf	tlgudenkauf@yousq.net	Owner	MAnchester	IA	United States	Lisa Gudenkauf	Brandon Mather	Signed
581	2021-07-22 14:29	Anonymous (not verified)	205.221.255.62	MartinHumphrey	Limited Liability Company	Cummins Rd. Apt 202	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-22	Martin Luverne Humphrey Jr.	martinhumphreu@gmail.com	Des Moines	Polk	Ioea	George Porter	Gerald Lund	Signed	(1) The employer does not elect the employers’ liability coverage.	Martin Luverne Humphrey Jr	martinhumphreu@gmail.com	Self	Des Moines	Polk	Iowa	George Porter	Gerald Lund	Signed
582	2021-07-22 15:14	Anonymous (not verified)	173.24.111.218	Joseph Davis	Proprietorship	7257 Valley 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.	2021-07-22	Joseph Davis	jtigerd@live.com	Bettendorf	Scott	IA	Jacob nagel	Nick brewer	Signed	(1) The employer does not elect the employers’ liability coverage.	Joseph Davis	jtigerd@live.com	Agent	Bettendorf	IA	IA	Jacob nagel	Nick brewer	Signed
857	2022-01-26 16:27	Anonymous (not verified)	207.199.212.86	Grahm's Tree Service	Proprietorship	406 2nd Ave 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.	2021-07-22	Graham Kuethe	lacy@cioia.com	Charles City	Floyd	Iowa	Lacy Carolan	Tony Trower	Signed	(1) The employer does not elect the employers’ liability coverage.	Graham Kuethe	lacy@cioia.com	Owner	Charles City	Floyd	Iowa	Lacy Carolan	Tony Trower	Signed
1750	2023-07-17 11:00	Anonymous (not verified)	94.188.205.166	Mario Flores	Proprietorship	2101 E Virginia Ave. Apt 1 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.	2021-07-22	Mario Zubia Flores	deb@piciowa.com	Des Moiines	Polk	Iowa	Inspro employee 2022	Inspro employee 2022	Signed	(1) The employer does not elect the employers’ liability coverage.	Mario Zubia Flores	deb@piciowa.com	self	Des Moines	Polk	Iowa	Inspro employee 2022	Inspro employee 2022	Signed
1751	2023-07-17 11:00	Anonymous (not verified)	94.188.205.166	Mario Flores	Proprietorship	2101 E Virginia Ave. Apt 1 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.	2021-07-22	Mario Zubia Flores	deb@piciowa.com	Des Moiines	Polk	Iowa	Inspro employee 2022	Inspro employee 2022	Signed	(1) The employer does not elect the employers’ liability coverage.	Mario Zubia Flores	deb@piciowa.com	self	Des Moines	Polk	Iowa	Inspro employee 2022	Inspro employee 2022	Signed
583	2021-07-23 12:37	Anonymous (not verified)	206.72.45.27	S&L Finishers LLC	Limited Liability Company	307 N 5th Street Mallard Ia 50562	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-23	Luke AKRIDGE	akridgel@ncn.net	Mallard	Palo Alto	United States	Kennedy Origer	Andy Wiita	Signed	(1) The employer does not elect the employers’ liability coverage.	Luke AKRIDGE	akridgel@ncn.net	Owner	MALLARD	IA	United States	Kennedy Origer	Andy Wiita	Signed
584	2021-07-23 15:38	Anonymous (not verified)	75.162.41.54	Bradens Roofing & Construction LLc	Limited Liability Company	2450 Hart Ave, 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.	2021-07-23	Arsenio Vargas	avargas409@gmail.com	Des Moines	Polk	Iowa	Marc Black	Jason Anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Arsenio Vargas	avargas409@gmail.com	Owner	Des Moines	Polk	Iowa	Marc Black	Jason Anderson	Signed
585	2021-07-25 20:07	Anonymous (not verified)	75.162.247.154	CJNR Works, LLC	Limited Liability Company	17003 Bowdin Crest Drive, Cypress, Texas 77433	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-25	Christopher Ridgway	christopherridgway@gmail.com	Cypress	Harris	TX	Sophia Ridgway	Mitchel Monahan	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher Ridgway	christopherridgway@gmail.com	Self	Cypress	Harris	TX	Sophia Ridgway	Mitchel Monahan	Signed
586	2021-07-26 08:37	Anonymous (not verified)	71.7.62.131	Jeffrey Knoot	Proprietorship	1251 Illinois Dr. Knoxville IA, 50138-8862	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-26	Jeffrey Jon Knoot	opsisdental@gmail.com	Knoxville	Marion	Iowa	Sharon Kay Spriggs	Lisa Michelle Dudley	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeffrey Jon Knoot	opsisdental@gmail.com	self	Knoxville	Marion	Iowa	Sharon Kay Spriggs	Lisa Michelle Dudley	Signed
587	2021-07-26 12:40	Anonymous (not verified)	172.56.7.208	Central Iowa Dict Cleaning	Proprietorship	1414 Adventureland Dr #4206 Altoona IA 50009	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-26	Gary Gallagher	ductclean@gmail.com	Altoona	Polk	IA	Meghan Militti	Todd Nastase	Signed	(1) The employer does not elect the employers’ liability coverage.	Gary Gallagher	ductclean@gmail.com	Self	Altoona	Polk	IA	Meghan Militti	Todd Nastase	Signed
589	2021-07-28 16:09	Anonymous (not verified)	97.125.35.240	Sotero Alonso Calderon Velasquez	Proprietorship	1312 Idaho 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.	2021-07-26	Sotero Alonso Calderon Velazquez	deb@piciowa.com	Des Moines	Polk	Iowa	Debra Stratton	Martin Pinon	Signed	(1) The employer does not elect the employers’ liability coverage.	Sotero Alonso Calderon Velazquez	deb@piciowa.com	subcontractor	Des MOines	Polk	Iowa	Debra Stratton	Martin Pinon	Signed
588	2021-07-27 19:59	Anonymous (not verified)	75.162.226.22	Andres Martinez	Limited Liability Company	3903 SW 3rd St. Des Moines, 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.	2021-07-27	Andres Martinez	and.am12am@gmail.com	Des Moines	Polk	Iowa	Carla Martinez	Librado Martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Andres Martinez	and.am12am@gmail.com	Employer	Des Moines	Polk	Iowa	Carla Martinez	Librado Martinez	Signed
590	2021-07-29 16:38	Anonymous (not verified)	138.43.237.95	Choice Ag Services INC	Proprietorship	1841 Firefly Rd, Manchester, IA 52057	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-29	Joshua Arthur Soppe	choiceagservices@gmail.com	Manchester	Delaware	Iowa	Dustin Fessler	Adam Reth	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua Arthur Soppe	choiceagservices@gmail.com	Owner	Manchester	Delaware	Iowa	Dustin Fessler	Adam Reth	Signed
591	2021-07-29 16:42	Anonymous (not verified)	138.43.237.95	Choice Ag Services INC	Proprietorship	1841 Firefly Rd, Manchester, IA 52057	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-29	Dustin Fessler	dustin@choiceagservices.com	Manchester	IA	United States	Josh Soppe	Adam Reth	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin Fessler	dustin@choiceagservices.com	Owner	Manchester	Delaware	Iowa	Josh Soppe	Adam Reth	Signed
592	2021-07-29 16:44	Anonymous (not verified)	138.43.237.95	Choice Ag Services INC	Proprietorship	1841 Firefly Rd, Manchester, IA 52057	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-29	Adam Reth	adam@choiceagservices.com	Manchester	IA	United States	Josh Soppe	Adam Reth	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Reth	adam@choiceagservices.com	Owner	Manchester	Delaware	Iowa	Josh Soppe	Dustin Fessler	Signed
594	2021-08-03 13:12	Anonymous (not verified)	166.181.80.73	Leaffilter	Limited Liability Company	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.	2021-08-03	Gerald Landstrum	Teamtony710@gmail.com	103 e Grinnell street Gibson Iowa	Keokuk	Iowa	Jake Nagel	Ty Reindl	Signed	(1) The employer does not elect the employers’ liability coverage.	LeafFilter Gutter Protection	jnagel@leafhome.com	assembler	Bettendorf	Scott	Iowa	Jake nagel	Ty reindl	Signed
595	2021-08-03 13:53	Anonymous (not verified)	174.248.224.252	Joseph r cunningham dba freedom field services	Proprietorship	6285 n 67th 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.	2021-08-03	Joseph r Cunningham jr.	joecunningham1966@protonmail.com	Baxter	Jasper	Iowa	Chelsey Cunningham	Chris Cort	Signed	(1) The employer does not elect the employers’ liability coverage.	Joseph r cunningham jr	joecunningham1966@protonmail.com	Me	Baxter	Jasper	Iowa	Chelsey cunningham	Chris cort	Signed
1774	2023-08-03 08:40	Anonymous (not verified)	94.188.205.168	J P Trucking, Inc.	Proprietorship	8768 White Tail Lane, Dubuque, IA 52003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-03	Jamison Noel	jptrucking.jamison@gmail.com	Dubuque	DBQ	Iowa	Lindsay Noel	Andy Kemp	Signed	(1) The employer does not elect the employers’ liability coverage.	Jamison Noel	jptrucking.jamison@gmail.com	Owner	Dubuque	Dubuque	Iowa	Lindsay Noel	Andy Kemp	Signed
596	2021-08-04 10:48	Anonymous (not verified)	184.80.177.137	Down Home Decor Inc	Proprietorship	1021 2nd Ave SE Ste 200 Dyersville, IA 52040	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-04	Steve Knipper	jheims@english-insurance.com	Dyersville	Dubuque	IA	Derrick Parsons	Joyce Heims	Signed	(1) The employer does not elect the employers’ liability coverage.	Joyce Heims	jheims@english-insurance.com	agent	Dyersville	Dubuque	IA	Derrick Parsons	Joyce Heims	Signed
1783	2023-08-04 10:17	Anonymous (not verified)	94.188.207.229	Lundin trucking llc	Limited Liability Company	322 w wilson street preston 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.	2021-08-04	Devin dallas lundin	devinlundin@hotmail.com	Preston	Jackson	Iowa	Kathy kilburg	Greg kilburg	Signed	(1) The employer does not elect the employers’ liability coverage.	Devin lundin	devinlundin@hotmail.com	Owner	Preston	Jackson	Iowa	Kathy kilburg	Greg kilburg	Signed
597	2021-08-05 13:38	Anonymous (not verified)	204.155.61.217	Haag Consulting LLC	Limited Liability Company	8602 E Kael Circle, Mesa, AZ 85207	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.	2021-08-05	Justin Haag	haag.justin1@gmail.com	Mesa	unknown	AZ	DocuSign	Ashley Kraft	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Haag	haag.justin1@gmail.com	Owner	Mesa	unknown	AZ	DocuSign	Ashley Kraft	Signed
598	2021-08-06 19:04	Anonymous (not verified)	107.77.208.84	Paul Adams	Proprietorship	914 Bayfield drive Denton TX 76209	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.	2021-08-06	Paul T Adams	ptadams61@yahoo.com	Denton	Denton	Tx	Jeanie Moses	Richard Moses	Signed	(1) The employer does not elect the employers’ liability coverage.	Paul T Adams	ptadams61@yahoo.com	Friends	Milan	Rock Island	Illinois	Jeanie Moses	Richard Moses	Signed
599	2021-08-09 22:57	Anonymous (not verified)	70.39.22.76	The Bartman Express LLC	Limited Liability Company	1976 240th St. Bennett IA 52721	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.	2021-08-09	Barton Steines	bartmanexpress@gmail.com	Bennett	Cedar	Iowa	Robert Jarrett	Michael Sexton	Signed	(1) The employer does not elect the employers’ liability coverage.	Barton Steines	bartmanexpress@gmail.com	Self	Bennett	Cedar	Iowa	Robert Jarrett	Michael Sexton	Signed
638	2021-09-13 09:18	Anonymous (not verified)	74.84.91.178	Thomas Tremble	Proprietorship	1209 University Avenue, 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.	2021-08-09	Thomas Tremble	TJTremble21@gmail.com	Dubuque	Dubuque	Iowa	Gabe Drewelow	Derrick Parsons	Signed	(1) The employer does not elect the employers’ liability coverage.	Thomas Tremble	TJTremble21@gmail.com	self	Dubuque	Dubuque	Iowa	Gabe Drewelow	Derrick Parsons	Signed
600	2021-08-12 11:04	Anonymous (not verified)	173.19.179.111	ELIJAH HIX	Proprietorship	PO BOX 465 MILFORD IA 51351	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-11	ELIJAH HIX	HIXSKIDOO800@GMAIL.COM	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	ELIJAH HIX	HIXSKIDOO800@GMAIL.COM	SELF	MILFORD	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed
601	2021-08-12 16:37	Anonymous (not verified)	172.58.83.7	C & G Construction LLC	Limited Liability Company	659 Sw Springfield 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.	(1) I am not electing the employers’ liability coverage.	2021-08-12	Griselda Corona	candgconst@gmail.com	Ankeny	Polk	IA	Clifton Kinney	Marisol Chavira	Signed	(1) The employer does not elect the employers’ liability coverage.	Juan Carlos corona	candgconst@gmail.com	Partner	Ankeny	Polk	IA	Clifton Kinney	Marisol Chavira	Signed
602	2021-08-13 22:49	Anonymous (not verified)	208.38.230.125	Granite & More	Limited Liability Company	4730, Tremont Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-14	Jin Chen	clteam563@gmail.com	Davenport	IA	United States	Jin Chen	Betty Song	Signed	(1) The employer does not elect the employers’ liability coverage.	Hong Le	clteam563@gmail.com	Self	Davenport	Scott	Iowa	Jin Chen	Betty Song	Signed
603	2021-08-14 09:39	Anonymous (not verified)	173.20.168.51	Leaf Filter	Proprietorship	3060 Southeast Grimes Boulevard	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-08-14	Francisco Salgado	fsalgado1989@gmail.com	Perry	IA	United States	Wendy Asturias	Susana Romero	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Leaf Filter	macosta@leafhome.com	none	Grimes	Polk	Iowa	Wendy Asturias	Susana Romero	Signed
604	2021-08-14 11:18	Anonymous (not verified)	69.54.119.134	Robert Curry	Limited Liability Company	10759 S 96th Ave W Prairie City IA 50228	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-14	Bob Curry	Gardengal4205@gmail.com	Prairie City	IA	United States	Megan Irwin	Rob Irwin	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Curry	Gardengal4205@gmail.com	Self	Prairie City	IA	United States	Megan Irwin	Rob Irwin	Signed
605	2021-08-16 16:06	Anonymous (not verified)	67.55.155.46	COMPLETE CONSTRUCTION SERVICES LLC	Limited Liability Company	718 FOX RUN	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.	2021-08-16	DAVID BOWER	BOWERD@OSKYCSD.ORG	OSKALOOSA	MAHASKA	IOWA	JAMES MCNAUL	CINDY STEVENSON GRUBB	Signed	(1) The employer does not elect the employers’ liability coverage.	DAVID BOWER	BOWERD@OSKYCSD.ORG	PRESIDENT	OSKALOOSA	MAHASKA	IOWA	JAMES MCNAUL	CINDY STEVENSON GRUBB	Signed

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