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:
1641	2023-05-11 13:40	Anonymous (not verified)	94.188.207.228	Mike Weigel Construction, LLC	Limited Liability Company	2528 Dalton St, Ames IA 50010-1151	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.	2023-05-11	Michael Patrick Weigel	mikeweigelconstruction@gmail.com	Ames	Story	Iowa	Brenda Marie Weigel	Piper Rylee Weigel	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Patrick Weigel	mikeweigelconstruction@gmail.com	Self	Ames	Story	Iowa	Brenda Marie Weigel	Piper Rylee Weigel	Signed
221	2020-08-03 12:03	Anonymous (not verified)	167.142.196.238	Israel Moreno	Proprietorship	Po Box 186 Williams, IA 50271	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.	2020-06-12	Israel Moreno	mikjuniormoreno@hotmail.com	Williams	Hamilton	Iowa	Justin J Malloy	Myndi Grimsley	Signed	(1) The employer does not elect the employers’ liability coverage.	Israel Moreno	mikjuniormoreno@hotmail.com	owner	Williams	Hamilton	Iowa	Justin J Malloy	Myndi Grimsley	Signed
1453	2023-02-14 07:19	Anonymous (not verified)	94.188.207.230	Milton Gray	Proprietorship	255 10th Ave., Marion, IA 52302, US	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.	2023-02-13	Milton Gray	miltongray23@gmail.com	Marion, IA	Linn	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	MO	Charles Wood	Steven Geisler	Signed
1729	2023-07-09 15:33	Anonymous (not verified)	94.188.207.223	Melvin A mineros	Limited Liability Company	6209 Windsor dr 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.	2023-07-09	Melvin A mineros	minerosframing.llc@gmail.com	Des moines	Polk	IA	Orlando dominguez	Isaac salazar	Signed	(1) The employer does not elect the employers’ liability coverage.	Jaime leiva	jaime@boersmaninsurance.com	Agent	Des moines	Polk	IA	Narciso hidalgo	Balmore perez	Signed
1778	2023-08-03 14:52	Anonymous (not verified)	94.188.207.227	Melvin A mineros	Limited Liability Company	6209 Windsor dr 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.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2023-06-22	Melvin alexander mineros	minerosframing.llc@gmail.com	Des moines	Polk	IA	Orlando dominguez	Isaac salazar	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jaime leiva	jaime@boersmaninsurance.com	Agent	Des moines	Polk	IA	Narciso hidalgo	Balmore perez	Signed
1015	2022-03-29 10:56	Anonymous (not verified)	129.255.1.117	Alli Center	Proprietorship	1150 5th St Suite 270 Coralville, IA 52241	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.	2022-03-29	Miranda K Maday	miranda.maday@alli-center.com	North Liberty	Johnson	Iowa	Zara Wanlass	Jason Knight	Signed	(1) The employer does not elect the employers’ liability coverage.	Zara Wanlass	zara.wanlass@alli-center.com	Co-Owner and Business Manager	Iowa City	Johnson	IA	Miranda K Maday	Jason Knight	Signed
2125	2024-03-28 23:17	Anonymous (not verified)	94.188.207.223	MB Lawn Care	Limited Liability Company	7018 Deerview Dr Urbandale IA 50322	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	Mirnes Becirovic	Mirnes2012@me.com	Urbandale	Polk	Iowa	Mirnes Becirovic	Mirnes Becirovic	Signed	(1) The employer does not elect the employers’ liability coverage.	Mirnes Becirovic	mirnes2012@me.com	Owner	Urbandale	Polk	Iowa	Mirnes Becirovic	Mirnes Becirovic	Signed
1512	2023-03-10 09:44	Anonymous (not verified)	94.188.205.169	eliseo isai	Proprietorship	5301 SE 24th St Des Moines, IA 50320 United States	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.	2023-03-08	eliseo isai carranza perez	Misaelballeza40@gmail.com	desmoines	polk	iowa	Julio Nolvela	giovanni nolvela	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	eliseo isai carranza perez	Misaelballeza40@gmail.com	self	desmoines	polk	iowa	Julio Nolvela	giovanni nolvela	Signed
27	2020-01-06 09:17	Anonymous (not verified)	24.149.10.119	Miss Wonderful LLC	Limited Liability Company	216 Main St Cedar Falls, IA 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.	2020-01-06	Ann Eastman	misswonderful216@gmail.com	Cedar Falls	Black Hawk	IA	Rachel Lee	Ann Remmert	Signed	(1) The employer does not elect the employers’ liability coverage.	Ann Eastman	misswonderful216@gmail.com	Owner	Cedar Falls	Black Hawk	IA	Rachel Lee	Ann Remmert	Signed
1799	2023-08-14 14:42	Anonymous (not verified)	94.188.205.174	Magiclean	Proprietorship	2001 S. 16th Burlington Iowa 52601	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.	2023-08-14	Sydney Bornsheuer	Mistycale@gmail.com	Burlington	Iowa	Iowa	Dustina Fenton	Doug Shupick	Signed	(1) The employer does not elect the employers’ liability coverage.	Misty Cale	magicleanburlington@gmail.com	Owner	Burlington	Des Moines	Iowa	Dustina Fenton	Doug Shupick	Signed
695	2021-10-26 17:22	Anonymous (not verified)	208.126.118.243	Godes Farms Trucking LLC	Limited Liability Company	1698 270th Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-26	Mitchel R Godes	mitchelgodes@hotmail.com	Delmar	clinton	iowa	Dustin Kyarsgaard	Mitch Moore	Signed	(1) The employer does not elect the employers’ liability coverage.	Mitchel R Godes	mitchelgodes@hotmail.com	owner	Delmar	Clinton	iowa	Dustin KKyarsgaard	Mitch Moore	Signed
1319	2022-09-22 11:31	Anonymous (not verified)	50.82.91.213	J. Thompson Builders, LLC	Limited Liability Company	5291 Stoney Creek Ct. Johnston, IA 50131	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-22	Mark Grant	mjgrant1957@gmail.com	Adel	Dallas	IA	Christina Viehauser	Jeremy Thompson	Signed	(1) The employer does not elect the employers’ liability coverage.	Christina Viehauser	christina@jthompsonbuilders.com	Office Help	Johnston Ia	Polk	IA	Chris Von Arx	Jeremy Thompson	Signed
1897	2023-11-06 09:12	Anonymous (not verified)	94.188.205.177	Matthew Jones	Limited Liability Company	124 NE 49th 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.	2023-11-06	Matthew Jones	mjj4242@gmail.com	Ankeny	Polk	IA	Duan Willform	AJ Giebelstein	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Jones	mjj4242@gmail.com	Self	Ankeny	Polk	IA	AJ Giebelstein	Duan Willform	Signed
721	2021-11-05 14:04	Anonymous (not verified)	209.252.172.87	Mike Kraus	Proprietorship	212 2nd St Buffalo, Ia 52728	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.	2020-03-17	Mike Kraus	mjkraus4356@gmail.com	Buffalo	Scott	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Mike Kraus	mjkraus4356@gmail.com	Self Employed	Buffalo	Scott	Iowa	Sarah Coberley	Heather Howell	Signed
58	2020-02-10 21:18	Anonymous (not verified)	75.162.11.63	Moni tile Services llc	Limited Liability Company	2207 E Walnut St des Moines iowa 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-01	Monica M Sandoval	Mjsandoval20@yahoo.com	Des Moines	Polk	United States	Cassie Ann bentz	James wesley harkert	Signed	(1) The employer does not elect the employers’ liability coverage.	Moni tile services llc	Mjsandoval20@yahoo.com	Self	Des Moines	Polk	Iowa	Cassie Ann bentz	James wesley harkert	Signed
213	2020-07-21 17:47	Anonymous (not verified)	107.77.206.41	Sequoia integrative medical services	Limited Liability Company	W2560 birschbach drive, mount Calvary, WI 53057	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.	2020-07-16	Mary Kate friess	mkfriess71@gmail.com	Fond du lac	Fond du lac	WI	Gordon Lewis	Ron carpenter	Signed	(1) The employer does not elect the employers’ liability coverage.	Mary Kate friess	mkfriess71@gmail.com	Self	Fond du lac	Fond du lac	Wi	Gordon Lewis	Ron carpenter	Signed
764	2021-11-22 15:33	Anonymous (not verified)	198.14.219.227	Central Iowa Painting and Contracting LLC	Limited Liability Company	408 Freel Drive, Ste. 101, Ames, IA 50010	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.	2021-11-22	Matthew Paul Klucas	mklucas50@gmail.com	Fort Dodge	Webster County	Iowa	Jordan Watkins	Scott Schuler	Signed	(1) The employer does not elect the employers’ liability coverage.	Matthew Klucas	mklucas50@gmail.com	Owner of Buisness	Fort Dodge	Webster County	Iowa	Jordan Watkins	Scott Schuler	Signed
4	2019-11-12 09:06	Anonymous (not verified)	174.71.54.19	M AND J LLC	Limited Liability Company	44100 STATE HIGHWAY 37 Dunlap, IA 51529	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.	2019-11-12	Mark Nichols	mknichols2003@yahoo.com	DUNLAP	Monona	IA	Damon Nichols	Bob Hall	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Nichols	mknichols2003@yahoo.com	Partner	Dunlap	Monona	IA	Damon Nichols	Bob Hall	Signed
5	2019-11-12 09:57	Anonymous (not verified)	174.71.54.19	M AND J LLC	Limited Liability Company	44100 STATE HIGHWAY 37	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.	2019-11-12	M AND J, LLC	mknichols2003@yahoo.com	DUNLAP	MONONA	IA	Damon Nichols	Bob Hall	Signed	(1) The employer does not elect the employers’ liability coverage.	JAMES MUMM	plipichok@yahoo.com	Partner	DUNLAP	MONONA	IA	DAMON NICHOLS	BOB HALL	Signed
15	2019-12-30 18:13	Anonymous (not verified)	104.166.243.52	Matt Moore	Proprietorship	8450 Hickman Road #15C	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.	2019-12-30	Matt Moore	mljm2016@outlook.com	Clive	Iowa	Iowa	Tom Onnen	James Buffington	Signed	(1) The employer does not elect the employers’ liability coverage.	Matt Moore	mljm2016@outlook.com	Subcontractor	Urbandale	IOWA	United States	Tom Onnen	James Buffington	Signed
145	2020-04-30 16:09	Anonymous (not verified)	173.191.206.253	Mark Knapp	Proprietorship	11244 Linden 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.	2020-04-30	Mark A Knapp	mlmlknapp@iowatelecom.net	Linden	Iowa	United States	Phil Hesseltine	Kathy Hesseltine	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Knapp	mlmlknapp@iowatelecom.net	self	Linden	Iowa	United States	Phil Hesseltine	Kathy Hesseltine	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
1514	2023-03-13 10:04	Anonymous (not verified)	94.188.205.166	MMK Electric	Limited Liability Partnership	4515 84th St 84th Street Urbandale, Iowa 50322	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.	2023-03-13	Travis Miller	mmk.iowa@gmail.com	Urbandale	Polk	Iowa	Elijah Kain	Marshall McKay	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Miller	mmk.iowa@gmail.com	Owner	Urbandale	Polk	Iowa	Elijah Kain	Marshall McKay	Signed
1520	2023-03-16 14:24	Anonymous (not verified)	94.188.205.167	MMK Electric	Partnership	4515 84th Street Urbandale, Iowa 50322	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.	2023-03-16	Marshall Logan McKay	mmk.iowa@gmail.com	Des Moines	Polk	Iowa	Travis Miller	Elijah Kain	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Miller	mmk.iowa@gmail.com	Owner	Urbandale	Polk	Iowa	Elijah Kain	Travis Miller	Signed
1521	2023-03-16 14:26	Anonymous (not verified)	94.188.207.229	Mmk electric	Partnership	4515 84th st Urbandale 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.	2023-03-16	Elijah dale kain	mmk.iowa@gmail.com	West Des moines	Polk	Iowa	Travis Lee miller	Marshall Logan McKay	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Lee miller	mmk.iowa@gmail.com	Owner	Urbandale	Polk	Iowa	Travis Lee miller	Marshall Logan mckay	Signed
660	2021-09-30 14:15	Anonymous (not verified)	172.58.86.219	LeafFilter	Limited Liability Company	3060 SE Grimes Blvd. Suite 100-300, Grimes, IA 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-30	Mohammed Albayati	mmm2002faris@yahoo.com	West Des Moines	Polk	Iowa	Tammy Decker	Yaseen Albayati	Signed	(1) The employer does not elect the employers’ liability coverage.	Mohammed Albayati	albayatim28@gmail.com	Employee	Grimes	Polk	Iowa	Tammy Decker	Yaseen Albayati	Signed
1771	2023-08-01 09:59	Anonymous (not verified)	94.188.207.223	Modern Builder LLC	Limited Liability Company	30008 560th St Chariton IA 50049	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.	2023-08-01	Tatyana Sayenko	modernbuilder02@gmail.com	Chariton	Lucas	Iowa	Arthur Sayenko	Viktor Sayenko	Signed	(1) The employer does not elect the employers’ liability coverage.	Tatyana Sayenko	modernbuilder02@gmail.com	owner/ Family	Chariton	Lucas	Iowa	Arthur Sayenko	Viktor Sayenko	Signed
1018	2022-03-29 15:00	Anonymous (not verified)	97.125.143.50	Modified Originals of Winterset	Limited Liability Company	128 S 3rd Ave, Winterset, IA 50273	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.	2022-03-29	Daniel Maiers	Modifiedoriginals.winterset@gmail.com	Winterset	Iowa	Iowa	Mark Haddinger	Josh Williams	Signed	(1) The employer does not elect the employers’ liability coverage.	Dan Maiers	Modifiedoriginals.winterset@gmail.com	Self	Winterset	Iowa	Iowa	Mark Haddinger	Josh Williamson	Signed
970	2022-03-14 14:08	Anonymous (not verified)	174.199.79.176	Friends Transportation Services LLC	Limited Liability Company	6010 Creston Ave Unit 26, Des Moines, IA 50321	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-14	Mohammed Dood	mohedali777@hotmail.com	Des Moines	Polk	Iowa	Leigh Laven	Geoff Matlock	Signed	(1) The employer does not elect the employers’ liability coverage.	Mohammed Dood	mohedali777@hotmail.com	Owner	Des Moines	Polk	Iowa	Leigh Laven	Geoff Matlock	Signed
1461	2023-02-17 07:48	Anonymous (not verified)	94.188.205.168	Great Blinds LLC	Limited Liability Company	5174 Parkridge Ave Pleasant Hill, IA 50327	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.	2023-02-17	Andrew Mohrfeld	mohrfeldandy@yahoo.com	Pleasant Hill	Polk	IA	Andrew Mohrfeld	Martin Mohrfeld	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	John Lovell	Jon@jlovellco.com	None	Urbandale	Polk	IA	Andrew Mohrfeld	Martin Mohrfeld	Signed
886	2022-02-03 10:21	Anonymous (not verified)	217.180.228.144	Flo + Friends, LLC	Limited Liability Company	52480 HWY 210 Slater, IA. 50244	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.	2022-02-03	Molly S Onken	mollyaols@gmail.com	Slater	Story	Iowa	Pam Wilson	Todd Wilson	Signed	(1) The employer does not elect the employers’ liability coverage.	Molly S Onken	mollyaols@gmail.com	self	slater	Story	Iowa	Pam Wilson	Todd Wilson	Signed
1481	2023-02-24 12:45	Anonymous (not verified)	94.188.207.223	Molly Onken	Limited Liability Company	52480 HWY 210 Slater, IA. 50244	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.	2023-02-20	Molly S Onken	mollyaols@gmail.com	Slater	Story	Iowa	Pamela A Wilson	Lori Konzen	Signed	(1) The employer does not elect the employers’ liability coverage.	Molly S Onken	mollyaols@gmail.com	Owner	Slater	Story	Iowa	Pamela A Wilson	Lori Konzen	Signed
71	2020-02-21 05:24	Anonymous (not verified)	70.100.107.197	CRS Inc.	Proprietorship	1442 3rd Ave SW	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.	2020-01-20	Monica Christensen	monicalchristensen@gmail.com	Belmond	Wright	Iowa	Jessica Tempus	Dawn Butler	Signed	(1) The employer does not elect the employers’ liability coverage.	Monica Christensen	monicalchristensen@gmail.com	Consultant	Belmond	Iowa	United States	Dawn Butler	Jessica Tempus	Signed
1858	2023-10-03 13:29	Anonymous (not verified)	94.188.207.223	Quad city drywall Solutions LLC	Limited Liability Company	5804 n thornwood ave 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.	2023-10-03	Erivan Emmanuel Montalvo Delcompare	montalvobills6@gmail.com	Davenport	Scott	Iowa	Natalia Ann Montalvo	Juan Portela	Signed	(1) The employer does not elect the employers’ liability coverage.	Erivan Emmanuel Montalvo Delcompare	montalvobills6@gmail.com	Owner	Davenport	Scott	Iowa	Natalia Montalvo	Juan Portela	Signed
774	2021-11-29 12:28	Anonymous (not verified)	174.198.82.208	Demetrio's Construction	Proprietorship	2018 Heights Ave Sioux City, IA 51104	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-29	Guillermo Demetrio	moralesdalia44@yahoo.com	Sioux City	Woodbury	Iowa	Dalia E. Morales Galvez	Vanessa Topete	Signed	(1) The employer does not elect the employers’ liability coverage.	Guillermo Demetrio	moralesdalia44@yahoo.com	Owner	Sioux City	Woodbury	Iowa	Dalia Morales Galvez	Vanessa Topete	Signed
1147	2022-06-08 11:29	Anonymous (not verified)	67.55.184.250	Morgan Anderson	Proprietorship	23379 120th Ave, Mediapolis, IA 52637	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.	2022-06-08	Morgan Duane Anderson	morgananderson6.ma@gmail.com	Mediapolis	IA	United States	Kelly S Lanz	Monte A Lanz	Signed	(1) The employer does not elect the employers’ liability coverage.	Morgan D. Anderson	morgananderson6.ma@gmail.com	sole proprietor	Mediapolis	Louisa	Iowa	Kelly Lanz	Monte Lanz	Signed
262	2020-09-18 13:54	Anonymous (not verified)	75.162.229.152	Morgan Group LLC	Limited Liability Company	1124 7th St. West Des Moines, IA 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.	2020-09-18	Mackinley Charles Morgan	MORGANGROUPLLC@GMAIL.COM	West Des Moines	Polk	Iowa	Mark Steven Morgan	Deborah Renee 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	Mark Steven Morgan	Deborah Renee Morgan	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
1041	2022-04-12 09:39	Anonymous (not verified)	173.31.148.43	PAPA'S SMOKIN MEAT	Proprietorship	1940 147TH 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.	2022-04-12	ROXANNE MORISTON	MORISTON2@YAHOO.COM	MONTGOMERY	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	ROXANNE MORISTON	MORISTON2@YAHOO.COM	SELF	MONTGOMERY	DICKINSON	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
2158	2024-04-17 11:47	Anonymous (not verified)	94.188.207.228	Mildred Lopez	Proprietorship	214 1st Ave SW Hampton, Iowa 50441	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.	2024-04-17	Mildred Lopez Camacho	morrison.hpd@gmail.com	Hampton	Franklin	Iowa	Ixia Anduce	Mark Morrison	Signed	(1) The employer does not elect the employers’ liability coverage.	Mildred Lopez	morrison.hpd@gmail.com	Self	Hampton	Franklin	IOwa	Ixia Anduce	Mark Morrison	Signed
2159	2024-04-17 12:28	Anonymous (not verified)	94.188.207.229	Mildred Lopez Camacho	Proprietorship	214 1st Ave SW Hampton, Iowa 50441	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.	2024-04-17	Mildred Lopez Camacho	morrison.hpd@gmail.com	Hampton	Franklin	Iowa	Ixia Anduce	Jonathan Morales	Signed	(1) The employer does not elect the employers’ liability coverage.	Mildred Lopez Camacho	morrison.hpd@gmail.com	Self	Hampton	Franklin	IOwa	Ixia Anduce	Jonathan Morales	Signed
258	2020-09-15 13:14	Anonymous (not verified)	50.83.182.140	Moyer Painting	Proprietorship	934 Norwood Drive	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-15	jerome Moyer	moyer_painting@live.com	Norwalk	IA	United States	Sally Moyer	Adam Adams	Signed	(1) The employer does not elect the employers’ liability coverage.	jerome b moyer	moyer_painting@live.com	Self	norwalk	IA	United States	sally moyer	Adam Adams	Signed
1335	2022-10-17 11:32	Anonymous (not verified)	71.39.227.238	PELZER AG LLC	Limited Liability Company	16864 280TH ST, REDFIELD, IA 50233	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-17	MATT PELZER	MPELZERFARMS@GMAIL.COM	REDFIELD	DALLAS	IOWA	ABBEY LUELLEN	DON RICHARDSON	Signed	(1) The employer does not elect the employers’ liability coverage.	MATT PELZER	MPELZERFARMS@GMAIL.COM	PRESIDENT	REDFIELD	DALLAS	IOWA	ABBEY LUELLEN	DON RICHARDSON	Signed
1144	2022-06-06 15:51	Anonymous (not verified)	63.152.93.184	Mark Moser	Limited Liability Company	904 W 4th St., Waterloo Iowa 50702	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-02	Mark Moser	mpmmoser@gmail.com	Waterloo	Black Hawk	Iowa	Timothy Combs	Teresa Tjaden	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Moser	mpmmoser@gmail.com	none	Waterloo	Black Hawk	Iowa	Timothy Combs	Teresa Tjaden	Signed
815	2021-12-28 12:29	Anonymous (not verified)	173.29.239.122	Comtek, Inc.	Proprietorship	3702 NW 13th St. Ankeny, Iowa 50023	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.	2021-12-28	Micheal D. Qualley	mqcomtek@gmail.com	ANKENY	IA	United States	Jacque Blackman	Jeffery Keipper	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacque Blackman	jblackman@grimesfinancialgroup.com	client	Grimes	Polk	Iowa	Jacque Blackman	Jeffery Keipper	Signed
1927	2023-11-29 13:13	Anonymous (not verified)	94.188.207.228	Yaardman landscaping llc	Limited Liability Company	51623 se seet cedar rapids iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-29	Adrian Pink	Mr.Pink1118@gmail.com	CEDAR RAPIDS	IA	United States	Andrea Parker	Kamar James	Signed	(1) The employer does not elect the employers’ liability coverage.	Adrian Pink	Mr.Pink1118@gmail.com	Owner	CEDAR RAPIDS	IA	United States	Andrea Parker	Kamar James	Signed
1938	2023-12-05 11:54	Anonymous (not verified)	94.188.207.225	Genius automotive	Limited Liability Company	51623 se seet cedar rapids iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-05	Adrian Pink	Mr.Pink1118@gmail.com	CEDAR RAPIDS	IA	United States	Andrea Parker	Kamar james	Signed	(1) The employer does not elect the employers’ liability coverage.	Adrian Pink	Mr.Pink1118@gmail.com	None	CEDAR RAPIDS	IA	United States	Andrea Parker	Kamar James	Signed
1233	2022-07-28 22:53	Anonymous (not verified)	166.181.84.53	Leaffilter	Limited Liability Company	3060 SE Grimes Blvd Suite 100-300, Grimes, IA 501113060 SE Grimes Blvd Suite 100-300, Grimes, IA 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-28	Mohammed Albayati	mrcarbody.81@gmail.com	Johnston	Polk	Iowa	Tammy Decker	Waffa Albayati	Signed	(1) The employer does not elect the employers’ liability coverage.	Meghan Mcilhon	mmcilhon@leaffilter.com	Human Resources	Grimes	Polk	Iowa	Tammy Decker	Waffa Albayati	Signed
411	2021-02-22 15:58	Anonymous (not verified)	173.24.190.134	The Willow Tree Garden Center	Limited Liability Company	2103 19rh Street, Emmetsburg IA 50536	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.	2021-02-22	Erica Janssen	mrjanz13@gmail.com	Emmetsburg	Palo Alto	Iowa	Marilee Lace	Candie Clark	Signed	(1) The employer does not elect the employers’ liability coverage.	Erica Janssen	mrjanz13@gmail.com	Member of LLC	Emmetsburg	Palo Alto	Iowa	Marilee Lace	Candie Clark	Signed
1030	2022-04-05 06:27	Anonymous (not verified)	172.58.86.173	MR Roofing LLC	Limited Liability Company	8012 Ashridge Rd. Fort Worth, Tx 76134	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.	2022-04-05	MR Roofing LLC	mrroofing.pr@gmail.com	Fort Worth	Tarrant	Texas	Juan M. Robledo	Jose A. Robledo	Signed	(1) The employer does not elect the employers’ liability coverage.	Paul Robledo	mrroofing.pr@gmail.com	Owner	Fort Worth	Tarrant	Texas	Juan M. Robledo	Jose A. Robledo	Signed

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