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:
1884	2023-10-27 18:32	Anonymous (not verified)	94.188.205.177	J&M dry wall	Proprietorship	948 Kern St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-27	Melecio Zacarias-Cano	Meleciozacarias29@gmail.com	Waterloo	Black hawk	IA	Luis flores	Luis flores	Signed	(1) The employer does not elect the employers’ liability coverage.	Melecio Zacarias-Cano	Meleciozacarias29@gmail.com	Self	Waterloo	Black hawk	IA	Luis Flores	Luis flores	Signed
798	2021-12-15 08:03	Anonymous (not verified)	173.22.84.26	LAMPE APPLIANCE SERVICE, Inc	Proprietorship	210 29TH ST NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-15	Jared J Lampe	lampeappliance@gmail.com	CEDAR RAPIDS	Linn	IA	Douglas James Lampe	John Kenneth Lampe	Signed	(1) The employer does not elect the employers’ liability coverage.	Douglas James Lampe	lampeappliance@gmail.com	Vice President	CEDAR RAPIDS	Linn	Iowa	Douglas James Lampe	John Kenneth Lampe	Signed
1357	2022-11-03 15:06	Anonymous (not verified)	66.129.196.99	Blake Carson	Limited Liability Company	1550 plainview rd ely, IA 52227	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.	2022-05-21	Blake Dennis Carson	Blake@carsondesignsco.com	Ely	Linn	iowa	Dennis Carson	Jordan Mellinger	Signed	(1) The employer does not elect the employers’ liability coverage.	Blake Carson	Blake@carsondesignsco.com	member/Owner	Ely	linn	iowa	Dennis Carson	Jordan Mellinger	Signed
1996	2024-01-24 10:30	Anonymous (not verified)	94.188.207.224	E&p quality home remodeling llc	Limited Liability Company	2660 NE 44th ct desmoines 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.	2024-01-24	Pedro martinez	pmsalas82@gmail.com	Des Moines	Polk	Iowa	Rogelio martinez	Rigoberto martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Pedro Martinez	pmsalas82@gmail.com	Owner	Des Moines	Polk	Iowa	Rogelio Martínez	Rigoberto Martínez	Signed
1469	2023-02-19 18:23	Anonymous (not verified)	94.188.205.169	Superior Sheet Metal LLC	Limited Liability Company	1819 MM Ave Marengo, IA 52301	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.	2023-02-19	Adam Lynn Nielsen	adamnielsen4@yahoo.com	Marengo	Iowa	United States	Emily Jean Nielsen	Joseph Daryl Kriegel	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Lynn Nielsen	adamnielsen4@yahoo.com	Self	Marengo	Iowa	Iowa	Emily Jean Nielsen	Joseph Daryl Kriegel	Signed
2108	2024-03-20 12:51	Anonymous (not verified)	94.188.207.230	Mc Storm Restortion Services	Limited Liability Company	1913 NE LITTLE BEAVER 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.	2024-03-20	Michael Cross	crossmichael1@hotmail.com	Grimes	IA	United States	Courtney Lesher	Chandler Steffy	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Cross	crossmichael1@hotmail.com	owner	Grimes	IA	United States	Courtney Lesher	Chandler Steffy	Signed
1581	2023-04-18 14:04	Anonymous (not verified)	94.188.205.177	L&J Services LLC	Limited Liability Company	6 highland acres rd marshalltown iowa 50158	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.	2023-04-18	Josh Colwell	centraliowa@fibrenew.com	Marshalltown	IA	United States	Micah Hesse	Hunter Bolinsger	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Colwell	centraliowa@fibrenew.com	Owner	Marshalltown	IA	United States	Micah Hesse	Hunter Bolsinger	Signed
2220	2024-05-10 11:10	Anonymous (not verified)	94.188.207.229	Froyo To Go, LLC	Limited Liability Company	909 4th Ave S., Denison, Iowa 51442	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-10	Lucas Gillmor	lgillmor@dmuonline.com	Denison	Crawford	Iowa	Maria Sandoval	Nahomy Fernandez Alvarado	Signed	(1) The employer does not elect the employers’ liability coverage.	Trevis Beeck	trevis.beeck.u0ms@statefarm.com	State Farm Agent	Denison	Crawford	Iowa	Maria Sandoval	Nahomy Fernandez Alvarado	Signed
1693	2023-06-16 11:37	Anonymous (not verified)	94.188.207.230	Anthony Scroggins	Proprietorship	301 SE 11th Street , Unit 807	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.	2023-06-16	Anthony Scroggins	scroggins710@gmail.com	Grimes	Polk	IA	Cody Wavada	Nate Duden	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony Scroggins	scroggins710@gmail.com	Self	Grimes	Polk	IA	Cody Wavada	Nate Duden	Signed
30	2020-01-07 08:34	Anonymous (not verified)	199.10.5.7	Data Information Management LLC	Limited Liability Company	703 Bluff St Dubuque 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.	2020-01-07	Stephen M Schauff	steve@caricomm.com	Dubuque	Iowa	IA	Janet L Schauff	Morris P Schauff	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher R Broessel	chris@caricomm.com	Partner	Dubuque	Iowa	IA	Janet L Schauff	Morris P schauff	Signed
142	2020-04-28 10:16	Anonymous (not verified)	74.84.101.138	Lutheran Cemetery Association	Proprietorship	410 S. Mechanic Street Decorah, IA 52101	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.	2020-02-18	Timothy A Stoddard	chelsea.whalen@upperiowains.com	Decorah	Winneshiek	IA	Robin C Schultz	Bobbi Jo Berg	Signed	(1) The employer does not elect the employers’ liability coverage.	Timothy A Stoddard	chelsea.whalen@upperiowains.com	Treasurer	Decorah	Winneshiek	IA	Robin C Schultz	Bobbi Jo Berg	Signed
254	2020-09-10 20:13	Anonymous (not verified)	97.127.219.61	Scott Woodward	Proprietorship	2619 west 69th St. davenport 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.	2020-09-10	Scott Woodward	woodwardscott2001@gmail.com	Davenport	Scott	Iowa	Scott Woodward	Scott Woodward	Signed	(1) The employer does not elect the employers’ liability coverage.	Scott Woodward	woodwardscott2001@gmail.com	Self employed	Davenport	Scott	Iowa	Scott Woodward	Scott Woodward	Signed
366	2021-01-18 18:32	Anonymous (not verified)	75.162.57.214	Affordable Exteriors, LLC	Limited Liability Company	802 east COUNTY LINE RD #57	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-18	Destiny Moses	Info@mktdsm.com	DES MOINES	IA	United States	Miguel Angel Garcia Ramirez	Nelly Bekker	Signed	(1) The employer does not elect the employers’ liability coverage.	Destiny Moses	Info@mktdsm.com	owner	DES MOINES	IA	United States	Miguel Garcia	Nellie Bekker	Signed
925	2022-02-17 13:07	Anonymous (not verified)	208.81.192.69	Wapsie Valley Construction, LLC	Limited Liability Company	1154 Dennison Ave., Fairbank, IA 50629	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-17	Chester H. Borntrager	accounting@robertseddy.com	Hazleton	Buchanan	Iowa	Brian C. Eddy	Samantha J. Stelter	Signed	(1) The employer does not elect the employers’ liability coverage.	Merle Miller	accounting@robertseddy.com	Same person	Fairbank	Buchanan	Iowa	Brian C. Eddy	Samantha J. Stelter	Signed
478	2021-04-14 13:18	Anonymous (not verified)	65.103.82.36	Fortress Lock & Key LLC	Proprietorship	1111 w 10th st. Davenport IA 52804	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.	2020-02-12	Paul Dunn	na@gmail.com	Davenport	Scott	IA	Jordan	Rose	Signed	(1) The employer does not elect the employers’ liability coverage.	Paul Dunn	na@gmail.com	Owner	Davenport	Scott	IA	jordan	Rose	Signed
1037	2022-04-07 08:16	Anonymous (not verified)	104.207.27.18	SION LUTHERAN CHURCH	Proprietorship	4525 FINCH AVE LAKE MILLS, IA 50450	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.	2021-03-07	JANE BRUNSVOLD	janebrunsvold@yahoo.com	LAKE MILLS	WINNEBAGO	IOWA	ANDREW STENSRUD	JILL FLUGUM	Signed	(1) The employer does not elect the employers’ liability coverage.	ANDREW STENSRUD	ANDREW@STENSRUDINSURANCE.COM	INSURANCE AGENT	LAKE MILLS	WINNEBAGO	IOWA	JANE BRUNSVOLD	JILL FLUGUM	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
1149	2022-06-09 17:43	Anonymous (not verified)	174.235.192.238	Bryan Linares	Limited Liability Company	630 Hawthorne 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.	2022-06-09	Bryan Linares	bryan.linares7798@gmail.com	Crete	Saline	Nebraska	Bryan Linares	Chris Linares	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher Linares	chris5linares1995@gmail.com	Brother	Crete	Saline	Nebraska	Bryan Linares	Chris Linares	Signed
1788	2023-08-07 18:32	Anonymous (not verified)	94.188.205.168	Johnson Custom Paint & Design LLC	Limited Liability Company	1414 N 9TH ST	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-07	Josh Johnson	johnsoncustompaint@hotmail.com	Fort Dodge	Iowa	United States	JACKLYN JOHNSON	Roger Johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua Johnson	johnsoncustompaint@hotmail.com	owner	Fort Dodge	IA	United States	JACKLYN JOHNSON	Roger Johnson	Signed
702	2021-11-01 09:23	Anonymous (not verified)	173.28.195.56	Garcia Snow Removal	Limited Liability Company	213 E 7th Street, West Liberty, Iowa 52776	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-01	Benji A Garcia	garciabenji23@gmail.com	West Liberty	IA	Norway	Luis Ordenana-Choez	Vicente Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Benji Garcia	garciabenji23@gmail.com	Member	West Liberty	Muscatine	Iowa	Luis Ordenana-Choez	Vicente Garcia	Signed
1261	2022-08-16 11:30	Anonymous (not verified)	173.29.47.222	Premiere Plastering & Drywall, Inc.	Proprietorship	2331 W. 63rd St., Davenport, IA 52806	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.	2022-08-16	Jacob Dreifurst	j_dreifurst@yahoo.com	Colona	Henry	Illinois	Jamie Wardlow	Kandra Blumenshein	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Premiere Plastering & Drywall, Inc.	premiere_pd_llc@yahoo.com	Subcontractor	Davenport	Iowa	United States	Jamie Wardlow	Kandra Blumenshein	Signed
1900	2023-11-09 23:24	Anonymous (not verified)	94.188.207.224	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.	2023-11-09	Daniel Blanco	chindan77@yahoo.com	Fort Dodge	IA	United States	Vanessa Blanco	Jorge Blanco	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Blanco	chindan77@yahoo.com	Self	Fort Dodge	IA	United States	Elva Castañeda	Vanessa Blanco	Signed
814	2021-12-27 13:07	Anonymous (not verified)	216.51.155.17	I & B Ag Supply, LLC	Limited Liability Company	3807 20th Ave Fenton, IA 50539	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.	2021-12-27	Israel Winter	israel.winter@hotmail.com	Fenton	Kossuth	Iowa	Jonathan Gesink	Benjamin Wiersma	Signed	(1) The employer does not elect the employers’ liability coverage.	Israel Winter	israel.winter@hotmail.com	Member	Fenton	Kossuth	Iowa	Jonathan Gesink	Benjamin Wiersma	Signed
1373	2022-11-16 12:28	Anonymous (not verified)	173.22.187.22	MCDONALD'S LAWN & TREE SERVICES	Proprietorship	1130 N. 4 AVE. W. NEWTON IA 50208	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.	2022-11-16	Roger McDonald	RABBITMCDONALD@HOTMAIL.COM	Newton	IA	United States	Patricia McMahon	Bryan McMahon	Signed	(1) The employer does not elect the employers’ liability coverage.	Roger McDonald	RABBITMCDONALD@HOTMAIL.COM	Self	Newton	IA	United States	Patricia McMahon	Bryan McMahon	Signed
2012	2024-01-31 10:38	Anonymous (not verified)	94.188.207.228	Mathew Soulis	Proprietorship	618 Boston Drive, Davenport, IA 52806	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.	2023-01-31	Mathew Soulis	mathew.soulis@gmail.com	Davenport	Scott	IA	Jordan Nisiewicz	Cody Dunbar	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	JNisiewicz@leafhome.com	Recruiter	Kansas City	Johnson	MO	Cody Dunbar	Monica Acosta	Signed
1485	2023-02-25 18:14	Anonymous (not verified)	94.188.205.177	J&V painting	Limited Liability Company	4759 woodland AV #56 West Des moines IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-25	Jessika Romero	jony.bel.vla@gmail.com	West Des Moines	Polk	Ia	Samir rahmanovic	Samir rahmanovic	Signed	(1) The employer does not elect the employers’ liability coverage.	Jessika Romero	jony.bel.vla@gmail.com	Self	West Des Moines	Polk	IA	Samir Rahmanovic	SAMIR RAHMANOVIC	Signed
2124	2024-03-28 13:47	Anonymous (not verified)	94.188.207.225	Gudiel Construction & Masonry LLC	Limited Liability Company	303 Lacona Ave Des Moines Iowa 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-28	Santiago Gudiel Lopez	gudielsantiago972@gmail.com	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Santiago Gudiel Lpez	gudielsantiago972@gmail.com	Self	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed
1597	2023-04-24 16:03	Anonymous (not verified)	94.188.207.224	4 Iowa Construction LLC	Limited Liability Company	1750 Lyon St Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-24	Luis E Cancino Mireles	luiscancino55@gmail.com	Des Moines	Polk	Iowa	Jon Buller	Terry Miles	Signed	(1) The employer does not elect the employers’ liability coverage.	Luis E Cancino Mireles	luiscancino55@gmail.com	self / 100% owner / manager of the LLC	Des Moines	Polk	Iowa	Jon Buller	Terry Miles	Signed
2236	2024-05-23 08:15	Anonymous (not verified)	94.188.207.227	Scg	Limited Liability Company	307 bridge st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-06	Oscar soto	oscarsoto25@yahoo.com	Amarillo	Randall	Texas	Brandon Degroff	Brian Patterson	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian patterson	brianpatterson@scgpipeline.com	Hr	Redfield	Dallas	Iowa	Brandon Degroff	Brian patterson	Signed
1709	2023-06-26 14:55	Anonymous (not verified)	94.188.205.177	Jeremy Pledge	Proprietorship	3310 East Washington Street, Iowa City, IA 52245	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.	2023-06-26	Jeremy Pledge	worknoplay8@gmail.com	Iowa City, IA	Johnson County	Iowa	Jordan Nisiewicz	Charles Wood	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Charles Woods	Jordan Loyd	Signed
46	2020-01-28 16:32	Anonymous (not verified)	173.18.3.76	Delic Marble and Tile LLC	Limited Liability Company	24 Ellefson Dr PO Box 413 DeSoto, IA 50069	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.	2020-01-27	Lutfija Delic	delicgraniteandtile@gmail.com	Adel	Dallas	Iowa	Angela Kinsey	Taylor Benshoof	Signed	(1) The employer does not elect the employers’ liability coverage.	Adin Delic	delicgraniteandtile@gmail.com	LLC Member	Adel	Dallas	Iowa	Angela Kinsey	Taylor Benshoof	Signed
158	2020-05-18 13:58	Anonymous (not verified)	108.59.100.21	LNM Truck & Trailer Repair LLC	Limited Liability Company	902 Rossville Rd, Waukon, IA 52172	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2020-05-18	Matthew Hawkins	lnmtruckandtrailerrepair@gmail.com	Waterville	Allamakee	IA	Jane M Regan	Chelsea Whalen	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Matthew Hawkins	lnmtruckandtrailerrepair@gmail.com	Owner	Waterville	Allamakee	IA	Jane M Regan	Chelsea Whalen	Signed
270	2020-09-25 10:14	Anonymous (not verified)	174.243.97.206	J Watts Electric	Limited Liability Company	615 E 2nd 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.	2020-09-25	Jason Watts	jason.watts@jwattselectric.com	Webster City	Hamilton	Iowa	Eli Ochoa	Cody Ewing	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason Watts	jason.watts@jwattselectric.com	Self	Webster City	Hamilton	Iowa	Eli Ochoa	Cody Ewing	Signed
382	2021-02-02 13:19	Anonymous (not verified)	192.30.185.142	Double D Weatherization	Proprietorship	2069 Glenn Ellen Rd, Sergeant Bluff, IA 51054	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-02	Dale Gernhart	lakehome@longlines.com	Sergeant Bluff	Woodbury	IA	Nate Blaeser	Jenni Ebner	Signed	(1) The employer does not elect the employers’ liability coverage.	Dale Gerhart	lakehome@longlines.com	Self	Sergeant Bluff	Woodbury	IA	Nate Blaeser	Jennie Ebner	Signed
941	2022-03-02 09:06	Anonymous (not verified)	173.18.150.140	515 Trucking, L.L.C.	Limited Liability Company	4613 E Valdez Dr, 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.	2022-03-02	Thomas L Garrett	515TruckHaul@gmail.com	Des Moines	Polk	Iowa	Shelley L Garrett	Sheila J Wyman	Signed	(1) The employer does not elect the employers’ liability coverage.	Thomas L Garrett	515TruckHaul@gmail.com	Owner	Des Moines	Polk	Iowa	Shelley L Garrett	Sheila J Wyman	Signed
494	2021-04-22 12:41	Anonymous (not verified)	173.18.16.129	Unique Drywall Finishing LLC	Limited Liability Company	509 E 26th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-22	jose angel chavez	uniquewal@yahoo.com	Des Moines	Polk	Iowa	Lesa Reeves	Jen Lambert	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Angel Chavez	uniquewal@yahoo.com	owner	Des Moines	Polk	Iowa	Lesa Reeves	Jen Lambert	Signed
1053	2022-04-14 21:08	Anonymous (not verified)	50.83.192.136	John E Snyder JR	Proprietorship	1677 PACIFIC ST, MURRAY, IA 50174	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.	2022-04-14	John Snyder JR	jrsweldingia@gmail.com	MURRAY	Clarke	Iowa	Shelly Goslar	Dorene Short	Signed	(1) The employer does not elect the employers’ liability coverage.	John Snyder JR	jrsweldingia@gmail.com	Selg	MURRAY	Clarke	Iowa	Shelly Goslar	Dorene Short	Signed
606	2021-08-17 12:25	Anonymous (not verified)	69.57.199.231	Precision Painting	Proprietorship	507 Broad St.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-08-17	Daniel Paul Bowser	danshonda12@gmail.com	Reinbeck	Grundy	Iowa	David Paul Bowser	Mary Ellen Sue Bowser	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Sinnott Agency	toms@sinnottagency.com	Insurance provider	Waterloo	Blackhawk	Iowa	David Paul Bowser	Mary Ellen Sue Bowser	Signed
1165	2022-06-23 09:28	Anonymous (not verified)	74.84.106.106	Rita Littrell	Proprietorship	620 N. 9th St., 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.	2022-06-23	Rita Littrell	ritaf1966@gmail.com	Carlisle	Warren	Iowa	Kimberly Owens	Tina Owens	Signed	(1) The employer does not elect the employers’ liability coverage.	Rita Littrell	ritaf1966@gmail.com	Self	Carlisle	Warren	Iowa	Kimberly Owens	Tina Owens	Signed
1804	2023-08-16 18:22	Anonymous (not verified)	94.188.207.226	Zach Moyle Masonry	Limited Liability Company	7222 Great River Rd	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.	2023-08-16	Zach Moyle	zmoylemasonry@gmail.com	Clermont	FAYETTE	FAYETTE	Brittney Loyd	Dave Moyle	Signed	(1) The employer does not elect the employers’ liability coverage.	Zach Moyle	zmoylemasonry@gmail.com	Self	Clermont	FAYETTE	FAYETTE	Brittney Loyd	Dave Moyle	Signed
718	2021-11-05 13:41	Anonymous (not verified)	209.252.172.87	Wayne Hunt	Proprietorship	405 E 4th St Tipton, Ia 52772	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.	2020-04-12	Wayne Hunt	installation@bachmeiercarpetone.com	Tipton	Cedar	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Wayne Hunt	installation@bachmeiercarpetone.com	Self	Tipton	Cedar	Iowa	Sarah Coberley	Heather Howell	Signed
1277	2022-08-22 08:57	Anonymous (not verified)	68.169.247.177	Andrew Betts	Proprietorship	305 3rd ave sw cascade 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.	2022-08-22	Andrew Betts	dbidrywallco@gmail.com	Cascade	Dubuque	Iowa	Jamie manternach	Andy hall	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Betts	dbidrywallco@gmail.com	Owner	Cascade	Iowa	United States	Jamie manternach	Andy hall	Signed
1916	2023-11-21 12:31	Anonymous (not verified)	94.188.205.174	DC Painting	Proprietorship	205 Astor St, Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-03	Damion Clement	gcort06@gmail.com	Des Moines	Polk	IA	Brandi Haight	Dennis Clement	Signed	(1) The employer does not elect the employers’ liability coverage.	Damion Clement	gcort06@gmail.com	Owner	205 Astor Street	Polk	IA	Brandi Haight	Dennis Clement	Signed
830	2022-01-11 16:18	Anonymous (not verified)	173.29.117.19	Leaf filter	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.	2022-01-11	Tom Ashby	tashby8@aol.com	Bettendorf	Scott County	IA	Veronica Ashby	Natalie Ashby	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Coleman	arcoleman@leafhome.com	Work coordinator	Bettendorf	Scott	IA	Veronica Ashby	Tom Ashby	Signed
1389	2022-12-11 12:36	Anonymous (not verified)	24.149.1.5	Project Fix It LLC	Limited Liability Company	1303 Washington Street Cedar Falls 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.	2022-12-12	Adam L Reiter	adam.reiter@projectfixit.net	Cedar Falls	IA	United States	Jennifer Reiter	Logan Reiter	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Project Fix It	adam.reiter@projectfixit.net	Owner	Cedar Falls	IA	United States	Jennifer Reiter	Logan Reiter	Signed
2028	2024-02-07 09:41	Anonymous (not verified)	94.188.207.228	J & J SIDING	Proprietorship	214 6TH STREET, P.O. BOX 482, LAKE VIEW, IOWA 51450	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-07	JOHN CLARENCE OLERICH	bigo@netins.net	LAKE VIEW	SAC	IOWA	ROBERT EUGENE BELT	NEIL THIESSEN MARTENS	Signed	(1) The employer does not elect the employers’ liability coverage.	JOHN CLARENCE OLERICH	bigo@netins.net	SELF	LAKE VIEW	SAC	IOWA	ROBERT EUGENE BELT	NEIL THIESSEN MARTENS	Signed
1501	2023-03-07 11:27	Anonymous (not verified)	94.188.205.167	Adriene Dangler	Proprietorship	2400 South Shore Dr Clear Lake, IA 50428	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.	2022-04-14	Adrienne Dangler	darrele@ciains.biz	Clear Lake	Cerro Gordo	Iowa	Darrel Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Darrel Elsbernd	darrele@ciains.biz	agent	Clear Lake	Cerro Gordo	Iowa	Darrel Elsbernd	Chris Fye	Signed
2140	2024-04-09 09:28	Anonymous (not verified)	94.188.205.175	Bart Fuller& James Fuller DBA Fuller & Sons	Partnership	1302 Lincoln Street Ruthven, IA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-09	Bart Fuller	goffins@ruthventel.com	Ruthven	Palo Alto	Iowa	Kathryn Kelley	Janice Henningsen	Signed	(1) The employer does not elect the employers’ liability coverage.	Bart Fuller	goffins@ruthventel.com	Partner	Ruthven	PAlo Alto	Iowa	Kathryn Kelley	Janice Henningsen	Signed
1613	2023-04-27 13:57	Anonymous (not verified)	94.188.207.227	Jacob's Ladder Construction	Proprietorship	406 10th st Dallas Center Ia 50063	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-27	Jacob Willis	jwillis924@gmail.com	Dallas Center	IA	United States	Anibal Bonilla	Ed Willis	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob A Willis	jwillis924@gmail.com	Owner	Dallas Center	IA	United States	Anibal Bonilla	Ed Willis	Signed
1725	2023-07-07 13:37	Anonymous (not verified)	94.188.205.167	Liana Fatino	Limited Liability Company	1930 se 14th des moines iowa 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.	2023-07-07	Liana Fatino	lfatino@yahoo.com	des moines	USA	Iowa	Liana Fatino	Gary Fatino	Signed	(1) The employer does not elect the employers’ liability coverage.	Liana Fatino	lfatino@yahoo.com	wife	des moines	USA	iowa	Liana Fatino	Gary Fatino	Signed

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