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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:
655 2021-09-24 15:28 Anonymous (not verified) 67.212.111.166 S Miller Painting LLC Limited Liability Company 1135 Barnett Drive, Cedar Falls, Iowa 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-24 Steven David Miller stevendm24@hotmail.com Cedar Falls Black Hawk Iowa Steve Koger Mark Miller Signed (1) The employer does not elect the employers’ liability coverage. Cory Allen koger coryspainting@gmail.com Self Cedar Falls Black Hawk Iowa Steve Koger Mark Miller Signed
654 2021-09-24 15:08 Anonymous (not verified) 199.247.64.87 Steve Porter DBA Precision Striping Proprietorship 408 Embassy Ct. 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. 2021-09-23 Steve Porter steve.porter2710@gmail.com Sergeant Bluff Woodbury Iowa Josh Nichols Steve Porter Signed (1) The employer does not elect the employers’ liability coverage. Jana Reich JNeuzil@reichpainting.com Office Manager Sioux City Woodbury Iowa Josh Nichols Steve Porter Signed
653 2021-09-23 15:03 Anonymous (not verified) 72.46.189.33 Feldkamp Farms Inc Partnership 5382 170th St Sibley IA 51249 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-23 Harold P Feldkamp joan@ellerbroekandassociates.com Sibley IA United States Wade Ellerbroek Jr Joan Wallace Signed (1) The employer does not elect the employers’ liability coverage. James Wade Ellerbroek Jr WADE@ELLERBROEKANDASSOCIATES.COM Agent only Sibley IA United States Wade Ellerbroek Jr Joan Wallace Signed
652 2021-09-22 21:52 Anonymous (not verified) 209.152.66.250 Robert Stutzman Limited Liability Company 33784 Hwy 22 Keota, IA 25548 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-22 Robert L Stutzman bnbstutzman@gmail.com Keota Keokuk Iowa Jo Edgington Amber Gent Signed (1) The employer does not elect the employers’ liability coverage. Sandra K Stutzman iafarmgirl90@gmail.com Daughter Keota Keokuk Iowa Jo Edgington Amber Gent Signed
651 2021-09-22 21:05 Anonymous (not verified) 174.198.68.116 Freedom field services LLC Limited Liability Company 6285 n 67 ave w. BAXTER IOWA 50028 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-22 joseph robert cunningham jr joecunningham1966@protonmail.com Baxter IA United States chelsey a cunningham jordan r cunningham Signed (1) The employer does not elect the employers’ liability coverage. joseph robert cunningham jr joecunningham1966@protonmail.com owner Baxter IA United States chelsey a cunningham jordan r cunningham Signed
650 2021-09-22 20:46 Anonymous (not verified) 174.198.68.116 Freedom field services Limited Liability Company 6285 n 67 ave w baxter iowa 50028 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-22 joseph robert cunningham jr joecunningham1966@protonmail.com Baxter IA United States chelsey a cunningham jordan r cunningham Signed (1) The employer does not elect the employers’ liability coverage. joseph robert cunningham jr joecunningham1966@protonmail.com owner Baxter IA United States chelsey a cunningham jordan r cunningham Signed
649 2021-09-21 13:15 Anonymous (not verified) 208.126.118.26 Wade Smith DBA WADA Farms Proprietorship 2428 270th st, Grand Mound, IA 52751 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. 2021-09-21 Wade Smith wade.smith1110@gmail.com Grand Mound Clinton Iowa Megan Fuglsang Jenny Gordon Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Wade Smith wade.smith1110@gmail.com self Grand Mound Clinton Iowa Megan Fuglsang Jenny Gordon Signed
648 2021-09-21 10:03 Anonymous (not verified) 97.125.32.164 Manuel Morales Proprietorship 1302 13th St Des Moines, Iowa 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. 2021-09-15 Manuel Morales deb@piciowa.com Des Moines Polk Iowa Deb Stratton Kelly Denger Signed (1) The employer does not elect the employers’ liability coverage. Manuel Morales deb@picowa.com subcontractor Des Moines Polk Iowa Deb Stratton Kelly Denger Signed
647 2021-09-20 10:37 Anonymous (not verified) 173.29.34.49 Brandon Jones Proprietorship 2043 3x Avenue I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-20 Brandon Dederick Jones Kaleb0430jones@gmail.com East Moline United States Illinois Brandon Jones Brandon Jones Signed (1) The employer does not elect the employers’ liability coverage. Brandon Dederick Jones Kaleb0430jones@gmail.com self East Moline United States Illinois Brandon Jones Brandon Jones Signed
646 2021-09-20 08:54 Anonymous (not verified) 173.24.107.209 QCA Professional Contractors Limited Liability Company 3314 67th 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. (1) I am not electing the employers’ liability coverage. 2021-09-20 Allan Celada allancelada@qcaprocontractors.com Moline Rock Island IL Alexander Celada Drexel Miller Signed (1) The employer does not elect the employers’ liability coverage. Allan Celada allancelada@qcaprocontractors.com self Moline Rock Island IL Alexander Celada Drexel Miller Signed
645 2021-09-18 09:47 Anonymous (not verified) 208.68.114.238 CHL Roofing & Siding Inc Proprietorship 509 1/2 E A St, West Liberty, IA 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. 2021-09-18 Fabian Galvan Rodriguez fgalvanglez14@gmail.com West Liberty Muscatine Iowa Karina A Beltran Nereida Velez Signed (1) The employer does not elect the employers’ liability coverage. Fabian Galvan Rodriguez fgalvanglez14@gmail.com Self West Liberty Muscatine Iowa Karina A Beltran Nereida Velez Signed
644 2021-09-17 11:20 Anonymous (not verified) 167.142.95.56 Preferred Properties of Iowa, Inc. Limited Liability Company 500 W. Temple St., Lenox, IA 50851 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-17 Brennan Kester mdpearson88@gmail.com Corning Taylor Iowa Ron Travis Maury Moore Signed (1) The employer does not elect the employers’ liability coverage. Dan Zech dan.ppi@gmail.com owner Lenox Taylor Iowa Ron Travis Maury Moore Signed
643 2021-09-17 11:17 Anonymous (not verified) 167.142.95.56 Preferred Properties of Iowa, Inc. Limited Liability Company 500 W. Temple St., Lenox, IA 50851 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-17 Mark Pearson mdpearson88@gmail.com Corning Adams Iowa Ron Travis Maury Moore Signed (1) The employer does not elect the employers’ liability coverage. Dan Zech dan.ppi@gmail.com Owner Lenox Taylor Iowa Ron Travis Maury Moore Signed
642 2021-09-17 11:09 Anonymous (not verified) 167.142.95.56 Preferred Properties of Iowa, Inc. Limited Liability Company 500 W. Temple 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. 2021-09-17 Daniel Zech dan.ppi@gmail.com Lenox Taylor Iowa Ron Travis Maury Moore Signed (1) The employer does not elect the employers’ liability coverage. Dan Zech dan.ppi@gmail.com Owner Lenox Taylor Iowa Ron Travis Maury Moore Signed
641 2021-09-17 09:16 Anonymous (not verified) 72.255.121.118 Osman Gonzalez-Sarceno Proprietorship 1403 Aspen Dr Adel, 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. 2021-09-17 Osman Gonzalez-Sarceno workorders@shoproyalflooring.com Des Moines Polk IA Melissa Bolanos Brianna Fuller Signed (1) The employer does not elect the employers’ liability coverage. Osman Gonzalez-Sarceno workorders@shoproyalflooring.com Owner Des Moines Polk Iowa Melissa Bolanos Brianna Fuller Signed
640 2021-09-16 22:43 Anonymous (not verified) 97.125.255.204 Morgan Group LLC Limited Liability Company 1124 7th St. West Des Moines, Iowa 50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-16 Mackinley Charles Morgan Morgangroupllc@gmail.com West Des Moines Polk Iowa Deborah Renee Morgan Mark Steven Morgan Signed (1) The employer does not elect the employers’ liability coverage. Mackinley Charles Morgan Morgangroupllc@gmail.com Owner of company West Des Moines Polk Iowa Deborah Renee Morgan Mark Steven Morgan Signed
639 2021-09-13 16:10 Anonymous (not verified) 50.81.97.207 Copic Home Maintenance LLC dba Des Moines Drywall Repair Limited Liability Company 1548 24th 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. 2021-09-13 Clint R Copic crcopic@gmail.com Des Moines Polk Iowa Veronica G. Torres Dan Waidelich Signed (1) The employer does not elect the employers’ liability coverage. Clint R Copic dmdrywallrepair@gmail.com self Des Moines Polk Iowa Veronica G Torres Dan Waidelich 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
637 2021-09-10 15:15 Anonymous (not verified) 204.155.61.217 Duwa Waterproofing LLC Limited Liability Company 1548 150th 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. 2021-09-10 Stacy Duwa duwawaterproofing@gmail.com Mt Pleasant Henry Iowa Jeffrey Spenner Shawn Powell Signed (1) The employer does not elect the employers’ liability coverage. Stacy Duwa duwawaterproofing@gmail.com owner Mt Pleasant Henry Iowa Jeffrey Spenner Shawn Powell Signed
636 2021-09-10 14:56 Anonymous (not verified) 173.19.179.111 SHANNON SUNDINE Proprietorship 513 16TH ST SPIRIT LAKE IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-10 SHANNON SUNDINE SPSUNDINE@GMAIL.COM SPIRIT LAKE DICKINSON IOWA TAMI KLEIN JENNIFER YOUNG WIRTH Signed (1) The employer does not elect the employers’ liability coverage. SHANNON SUNDINE SPSUNDINE@GMAIL.COM SELF SPIRIT LAKE DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
635 2021-09-10 13:41 Anonymous (not verified) 166.181.84.226 JZH Roofing Specialists LLC Limited Liability Company 2127 Swan Dr, Norwalk, Iowa. 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-10 Jayme Alexander Christian Heiselman wrkhrd2plyhrd04@gmail.com Norwalk Warren Iowa Melanie Handy Jesse Hagge Signed (1) The employer does not elect the employers’ liability coverage. Jayme Alexander Christian Heiselman wrkhrd2plyhrd04@gmail.com Single member Norwalk Warren Iowa Melanie Handy Jesse Hagge Signed
634 2021-09-10 13:41 Anonymous (not verified) 173.23.145.231 julio medina Proprietorship 609 boyd st. des moines, iowa 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-10 julio medina medinajulio10001@gmail.com des moines polk iowa jose rivas Virginia Gomez Signed (1) The employer does not elect the employers’ liability coverage. Julio Medina medinajulio10001@gmail.com owner des moines polk iowa jose Rivas Virginia Gomez Signed
633 2021-09-08 10:35 Anonymous (not verified) 208.95.1.97 BAJ Flooring, LLC Limited Liability Company 31533 Castle Ct. Dyersville, IA. 52040-7600 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. 2021-09-08 Brian Jacque JacqueBrian18@gmail.com Dyersville Dubuque Iowa Stephen J. Schluter Paula Fitzgerald Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Brian A. Jacque JacqueBrian18@gmail.com LLC MEMBER Dyersville DUBUQUE IOWA Stephen J. Schlueter Stephen J. Schlueter Signed
632 2021-09-07 13:42 Anonymous (not verified) 50.82.130.211 Thomas Mann Proprietorship 401 Miners Street, Parkersburg, 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. 2021-09-09 Thomas Mann cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Thomas Mann cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
631 2021-09-02 22:46 Anonymous (not verified) 173.23.144.4 Lopez Framing LLC Limited Liability Company 566 walker 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. 2021-09-02 Diana A Garcia Lopez lopezframing0702@gmail.com Des moines Polk Iowa Marlon Lopez Jennifer Reyes Signed (1) The employer does not elect the employers’ liability coverage. Diana A Garcia Lopez lopezframing0702@gmail.com Owner Des moines Polk Iowa Marlon Lopez Jennifer Reyes Signed
630 2021-09-01 19:29 Anonymous (not verified) 97.125.133.79 Aaron J. Rosenbaum Proprietorship 2005 Pine St, Granger, IA 50109 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-01 Aaron J. Rosenbaum aabaum7@gmail.com Granger Dallas Iowa Bruce Klinkenberg Trudy Rosenbaum Signed (1) The employer does not elect the employers’ liability coverage. Aaron Rosenbaum aabaum7@gmail.com self Granger Dallas Iowa Bruce Klinkenberg Trudy Rosenbaum Signed
629 2021-09-01 09:44 Anonymous (not verified) 204.155.61.217 Thrapp Electric Proprietorship 708 2nd Street Wellman, Iowa 52356 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-01 Jay Thrapp socketman5555@hotmail.com Wellman Washington Iowa Jeffrey Spenner Shawn Powell Signed (1) The employer does not elect the employers’ liability coverage. Jay Thrapp socketman5555@hotmail.com Owner Wellman Washington Iowa Jeffrey Spenner Shawn Powell Signed
628 2021-09-01 09:39 Anonymous (not verified) 204.155.61.217 Utzinger Epoxy & Concrete, LLC Limited Liability Company 1595 Highway 1 Washington, Iowa 52353 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-01 Troy Utzinger tbutzinger99@kctc.net Washington Washington Iowa Jeffrey Spenner Shawn Powell Signed (1) The employer does not elect the employers’ liability coverage. Troy Utzinger tbutzinger99@kctc.net owner Washington Washington Iowa Jeffrey Spenner Shawn Powell Signed
627 2021-08-31 16:12 Anonymous (not verified) 173.18.16.129 D's Home Improvement Limited Liability Company 665 27th St Des Moines IA 50312 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. 2021-08-31 Dustin Mitchell dustinmitchell8855@gmail.com Des Moines Polk Iowa Lesa Reeves Kelly Coluzzi Signed (1) The employer does not elect the employers’ liability coverage. Dustin Mitchell dustinmitchell8855@gmail.com Owner Des Moines Polk IA Lesa Reeves Kelly Coluzzi Signed
626 2021-08-31 11:39 Anonymous (not verified) 166.181.81.253 Birds landscape maintenance LLC Limited Liability Company 1307 w 4th st south 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. 2021-08-31 Michael Alan bird birdslawn@hotmail.com Newton Jasper Iowa Jeff Dennis carder Dustin James bos Signed (1) The employer does not elect the employers’ liability coverage. Michael Alan bird birdslawn@hotmail.com Same - owner Newton Jasper Iowa Jeff Dennis carder Dustin James bos Signed
625 2021-08-30 20:39 Anonymous (not verified) 173.16.140.101 Phthalo Consulting LLC Limited Liability Company 2917 47th St, Des Moines, IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-30 Angela Stone-Wiegert angela@phthaloconsulting.com Des Moines Polk Iowa Sonya Shippy Kenny Shippy Signed (1) The employer does not elect the employers’ liability coverage. Angela Stone-Wiegert angela@phthaloconsulting.com Owner Des Moines Polk Iowa Sonya Shippy Kenny Shippy Signed
624 2021-08-30 15:53 Anonymous (not verified) 174.253.66.113 Leaf Home Solutions LLC Limited Liability Company 1595 Georgetown 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. 2021-08-30 Chad York Cyork027@gmail.com Davenport Scott Iowa Chad York Adam Coleman Signed (1) The employer does not elect the employers’ liability coverage. Adam Coleman ARColeman@leafhome.com Recruiter Hudson Summit Ohio Chad York Adam Coleman Signed
623 2021-08-30 15:03 Anonymous (not verified) 174.198.77.231 Joe Dawson Proprietorship 1088, Dogwood Avenue I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-30 Joe R Dawson joerdawson@gmail.com Coon Rapids IA United States Linda Doran Megan Specht Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Joe R Dawson joerdawson@gmail.com Owner Coon Rapids IA United States Linda Doran Megan Specht Signed
622 2021-08-27 16:12 Anonymous (not verified) 71.39.227.238 DOUG AND ELLEN WEISS DBA DIRTWORKS Proprietorship 23966 MIDLAND TRAIL, 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. 2021-08-27 ELLEN WEISS EWEISSN03.EW@GMAIL.COM DALLAS CENTER DALLAS IOWA DON RICHARDSON ABBEY LUELLEN Signed (1) The employer does not elect the employers’ liability coverage. ELLEN WEISS EWISSN03.EW@GMAIL.COM SELF DALLAS CENTER DALLAS IOWA DON RICHARDSON ABBEY LUELLEN Signed
621 2021-08-27 16:11 Anonymous (not verified) 71.39.227.238 DOUG WEISS DBA DIRTWORKS Proprietorship 23966 MIDLAND TRAIL, 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. 2021-08-27 DOUG WEISS EWEISSN03.EW@GMAIL.COM DALLAS CENTER DALLAS IOWA DON RICHARDSON ABBEY LUELLEN Signed (1) The employer does not elect the employers’ liability coverage. DOUG WEISS EWEISSN03.EW@GMAIL.COM SELF DALLAS CENTER DALLAS IOWA DON RICHARDSON ABBEY LUELLEN Signed
620 2021-08-26 16:26 Anonymous (not verified) 75.162.146.246 Daniel Meza Reyes Proprietorship 1640 E Army Post RD 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. 2021-08-23 Daniel Meza Reyes danielmr9247@gmail.com Des Moines polk IA Yolanda Mendoza Liliana Sanchez Signed (1) The employer does not elect the employers’ liability coverage. Daniel Meza Reyes danielmr9247@gmail.com self Des Moines polk IA Yolanda Mendoza Liliana Sanchez Signed
619 2021-08-25 14:31 Anonymous (not verified) 192.154.15.2 MAV Restorations LLC Limited Liability Company 5461 Meadow Ct, Asbury, IA 52002 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. 2021-08-25 Matthew Vaske mlvaske@gmail.com Asbury Dubuque IA Randi Taylor Carla Martin Signed (1) The employer does not elect the employers’ liability coverage. Matthew Vaske mlvaske@gmail.com Self Asbury Dubuque IA Randi Taylor Carla Martin Signed
618 2021-08-23 15:17 Anonymous (not verified) 173.17.131.91 Leaffilter North of Iowa, LLC Proprietorship 5650 NW Johnston IA 50131 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-23 Jorge Meraz jmaraz961@gmail.com 2906 e madison avenue Des moines IA Jisel chaves Melvin arevalo Signed (1) The employer does not elect the employers’ liability coverage. Jorge meraz jmeraz961@gmail.com Self Des moines Des moine IA Jusel chavez Melvin arevalo Signed
617 2021-08-23 13:58 Anonymous (not verified) 172.58.84.152 Jose barrientos Proprietorship 1844 n tony ln 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. 2021-08-23 Jose Barrientos 70barrientos70@gmail.com Wichita Sedwick Kansas Roberto valle Juan lopez Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jose barrientos 70barrientos70@gmail.com Employer Wichita Sedwick Kansas Vladimir faustino Rene Grande Signed
616 2021-08-23 13:14 Anonymous (not verified) 173.25.153.19 Levon Proprietorship 210 S 41st 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. 2021-08-23 Levon shheba sheebalevon@gmail.com West des Moines IA 50265 Polk county IA Alina sheeba Delon sheeba Signed (1) The employer does not elect the employers’ liability coverage. Levon sheeba sheebalevon@gmail.com Myself West des Moines IA 50265 Polk county IA Alina sheeba Delon sheeba Signed
615 2021-08-20 16:22 Anonymous (not verified) 50.81.152.147 CPIA Home Specialists LLC Limited Liability Company 1214 13th 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. 2021-08-20 Melvin Benitez Benitezmelvin0@gmail.com Des Moines Iowa United States Salvador Benitez Zoila Benitez Signed (1) The employer does not elect the employers’ liability coverage. Melvin Benitez Benitezmelvin0@gmail.com Owner Des Moines Iowa United States Salvador Benitez Zoila Benitez Signed
614 2021-08-20 12:20 Anonymous (not verified) 172.58.235.242 Darren Qualls Proprietorship 1515 Dewitt St. Ellsworth. IA 50075 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. 2021-08-20 Darren Wade Qualls d.qualls@outlook.com Ellsworth Hamilton IA Jeannie Kathleen Qualls Andrea Littleton Signed (1) The employer does not elect the employers’ liability coverage. Darren Wade Qualls d.qualls@outlook.com Self/Proprietor Ellsworth IA IA Jeannie Kathleen Qualls Andrea Littleton Signed
613 2021-08-19 21:54 Anonymous (not verified) 50.82.65.174 33z Racing, LLC Limited Liability Company 307 N Park Ave, New Sharon, Iowa 50207 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. 2021-08-20 Zackery J VanderBeek zackvanderbeek@gmail.com New Sharon Mahaska IA Margaret Ratcliff Billy Blake Signed (1) The employer does not elect the employers’ liability coverage. Barbara M VanderBeek bvanderbeek33z@gmail.com Mother New Sharon Mahaska IA Margaret Ratcliff Billy Blake Signed
612 2021-08-19 21:50 Anonymous (not verified) 50.82.65.174 33z Racing,, LLC Limited Liability Company 307 N Park Ave, New Sharon, Iowa 50207 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. 2021-08-20 James Dean VanderBeek jvanderbeek@plbco.com New Sharon Mahaska Iowa Margaret Ratcliff Billy Blake Signed (1) The employer does not elect the employers’ liability coverage. Barbara M VanderBeek bvanderbeek33z@gmail.com Spouse New Sharon Mahaska Iowa Margaret Ratcliff Billy Blake Signed
611 2021-08-19 15:23 Anonymous (not verified) 97.125.53.119 Rogelio Lopez Casillas Proprietorship 1175 Office Park Road Apt 109 WDM, Iowa 50265 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. 2021-08-21 Rogelio Lopez Casillas deb@piciowa.com West Des Moines Polk Iowa Debra Stratton Kelly K Denger Signed (1) The employer does not elect the employers’ liability coverage. Rogelio Lopez Casillas deb@piciowa.com subcontractor West Des Moines Polk Iowa Debra Stratton Kelly K Denger Signed
610 2021-08-18 11:15 Anonymous (not verified) 172.58.84.99 LeafFilter North LLC Partnership 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. 2021-08-18 Thomas R Fuller tomstl001@yahoo.com DAVENPORT Iowa Iowa Bob phillips Julie fuller Signed (1) The employer does not elect the employers’ liability coverage. Jordan nisiewicz jnisiewicz@leafhome.com Regional field recruiter Bettendorf iowa Scott Iowa Warren crow Jordan lloyd Signed
609 2021-08-17 21:42 Anonymous (not verified) 50.82.65.174 33z Racing, LLC Limited Liability Company 307 N Park Ave, New Sharon, IA. 50207 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. 2021-08-17 Zackery James VanderBeek zackvanderbeek@gmail.com New Sharon Mahaska IA Barbara M VanderBeek James. VanderBeek Signed (1) The employer does not elect the employers’ liability coverage. Barbara M VanderBeek bvanderbeek33z@gmail.com Mother New Sharon Mahaska IA James D VanderBeek Barbara M VanderBeek Signed
608 2021-08-17 21:35 Anonymous (not verified) 50.82.65.174 33z Racing, LLC Limited Liability Company 307 N Park Ave, New Sharon, IA. 50207 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. 2021-08-17 James D VanderBeek jvanderbeek@plbci.com New Sharon Mahaska IA Barbara M VanderBeek Zackery James VanderBeek Signed (1) The employer does not elect the employers’ liability coverage. Barbara M VanderBeek bvanderbeek33z@gmail.com Spouse New Sharon Mahaska IA James D VanderBeek Zackery J VanderBeek Signed
607 2021-08-17 12:31 Anonymous (not verified) 69.57.199.231 Precsion 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. (1) I am not electing the employers’ liability coverage. 2021-08-17 Daniel Paul Bowser danshonda12@gmail.com Reinbeck Grundy Iowa David Paul Bowser Mary Ellen Sue Bowser Signed (1) The employer does not elect the employers’ liability coverage. Sinnott Agency toms@sinnottagency.com Insurance provider Waterloo Blackhawk Iowa David Paul Bowser Mary Ellen Sue Bowser 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