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:
2200	2024-05-06 08:46	Anonymous (not verified)	94.188.207.226	Dominguez Construction LLC	Limited Liability Company	1680 East Emma 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.	2024-05-05	Ramon Dominguez	3memincolina@gmail.com	Des Moines	Polk	Iowa	Nathan Miller	Stacey Lazear	Signed	(1) The employer does not elect the employers’ liability coverage.	Ramon Dominquez	3memincolina@gmail.com	Owner	Des Moines	Polk	Iowa	Nathan Miller	Stacey Lazear	Signed
1915	2023-11-21 04:06	Anonymous (not verified)	94.188.207.225	Advanced Foam Systems	Limited Liability Company	1378 Midway Ave Tripoli IA 50676	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.	2023-11-18	Randy Block	advancedfoamsystems@yahoo.com	Tripoli	Bremer	Iowa	Linda Block	Brady Block	Signed	(1) The employer does not elect the employers’ liability coverage.	Randy Block	advancedfoamsystems@yahoo.com	Me	Tripoli	Bremer	Iowa	Linda block	Brady block	Signed
843	2022-01-20 07:48	Anonymous (not verified)	207.199.230.75	Heart of Iowa Inspections LLC	Limited Liability Company	2700 Highway 63 Oskaloosa, Iowa 52577	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.	2022-01-20	Randy DeHeer	rdenheer2828@gmail.com	Oskaloosa	Mahaska	Iowa	Cheryl Brown	Doris Crile	Signed	(1) The employer does not elect the employers’ liability coverage.	Randy DeHeer	rdenheer2828@gmail.com	self	Oskaloosa	Mahaska	Iowa	Cheryl Brown	Doris Crile	Signed
934	2022-02-23 12:13	Anonymous (not verified)	207.199.230.75	Randy DeHeer	Limited Liability Company	2700 Highway 63 Oskaloosa, Iowa 52577	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.	2022-02-23	Randy DeHeer	rdeheer2828@gmail.com	Oskaloosa	Mahaska	Jowa	Cheryl Brown	Doris Crile	Signed	(1) The employer does not elect the employers’ liability coverage.	Randy DeHeer	rdeheer2828@gmail.com	Self	Oskaloosa	Mahaska	Iowa	Cheryl Brown	Doris Crile	Signed
1961	2023-12-16 12:22	Anonymous (not verified)	94.188.207.228	Randy Hove	Proprietorship	2376 370th St. Jewell. Iowa. 50130	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.	2023-12-14	Randy Gordon Hove	mandrhove@gmail.com	Jewell	Hamilton	Iowa	Ryan Drzycimski	Casey Westling	Signed	(1) The employer does not elect the employers’ liability coverage.	Randy	mandrhove@gmail.com	Same	Same	Same	Same	Same	Same	Signed
1355	2022-11-01 11:06	Anonymous (not verified)	23.252.149.120	Randy J. Hackenmiller dba Hackenmiller Trucking	Proprietorship	606 Grain Millers Dr. PO Box 125, St. Ansgar, IA 50472-0125	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-01	Randy J. Hackenmiller	randhack@myomnitel.com	St. Ansgar	Mitchell	Iowa	Kent A. Wilder	Rebecca L. Dobson	Signed	(1) The employer does not elect the employers’ liability coverage.	Randy J. Hackenmiller	randhack@myomnitel.com	Self	St. Ansgar	Mitchell	Iowa	Kent A. Wilder	Rebecca L. Dobson	Signed
1807	2023-08-17 12:45	Anonymous (not verified)	94.188.205.175	LONE STAR ROOFING, LLC	Limited Liability Company	4021 WINDSOR CT 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.	2023-08-17	RAQUEL B DIAZ MENENDEZ	LONE.STAR.ROOFING76@GMAIL.COM	DES MOINES	USA	IOWA	LILIANA SANCHEZ	RENE ALEXANDER VELASCO	Signed	(1) The employer does not elect the employers’ liability coverage.	LONE STAR ROOFING, LLC	LONE.STAR.ROOFING76@GMAIL.COM	MEMBER OWNER	DES MOINES	USA	IOWA	LILIANA SANCHEZ	RENE ALEXANDER VELASCO	Signed
69	2020-02-19 15:58	Anonymous (not verified)	198.14.241.59	MORENOS C ROOFING LLC	Limited Liability Company	2018 WATERFRONT DR LOT 73 IOWA CITY IA 52240	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.	2020-02-19	RAQUEL OLEA CAMACHO	JORGETREJO19896@GMAIL.COM	IOWA CITY	JOHNSON	IOWA	JORGE TREJO	JOSE SALGADO	Signed	(1) The employer does not elect the employers’ liability coverage.	RAQUEL OLEA CAMACHO	JORGETREJO19896@GMAIL.COM	OWNER	IOWA CITY	JOHNSON	IOWA	JORGE TREJO	JOSE SALGADO	Signed
1980	2024-01-10 11:32	Anonymous (not verified)	94.188.207.224	Raudel Correa	Proprietorship	1924 23rd St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-02	Raudel Correa	deb@piciowa.com	Des Moines	Polk	Iowa	Martin Pinon	Debra Stratton	Signed	(1) The employer does not elect the employers’ liability coverage.	Raudel Correa	deb@piciowa.com	self	Des Moines	Polk	Iowa	Martin Pinon	Debra Stratton	Signed
1672	2023-06-01 15:16	Anonymous (not verified)	94.188.207.224	Raudel Correa Correa	Proprietorship	1924 23rd 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.	2023-06-01	Raudel Correa Correa	correaraudel6@gmail.com	Des Moines	Polk	Iowa	Debra Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Raudel Correa Correa	correaraudel6@gmail.com	self	DM	Polk	IA	Den Stratton	Kelly Denger	Signed
1285	2022-08-26 08:22	Anonymous (not verified)	97.125.43.203	Raul Villanueva	Proprietorship	6901 SE 14th #71	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-24	Raul Villanueva	deb@piciowa.com	Des Moines	Polk	Iowa	Debra Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Raul Villanueva	deb@picowa.com	self	Des Moines	Polk	IA	Debra Stratton	Kelly Denger	Signed
1650	2023-05-16 12:06	Anonymous (not verified)	94.188.207.225	R & J Transport	Proprietorship	85152 US HWY 81 PIERCE NE 68767	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.	2023-05-16	Ray Tom Clausen III	jamieleabeutler2013@gmail.com	Pierce	NE	United States	Jamie Clausen	Ann Siebrandt	Signed	(1) The employer does not elect the employers’ liability coverage.	Ray T Clausen III	jamieleabeutler2013@gmail.com	Owner	Pierce	Pierce	Ne	Jamie Clausen	Ann Siebrandt	Signed
1484	2023-02-25 16:42	Anonymous (not verified)	94.188.205.177	Carpenter wood shed/ rays longging	Limited Liability Company	1631 230th st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-27	Raymond Carpenter	corinnafrymoyer@gmail.com	tipton	Cedar	Iowa	corinna frymoyer	Levi carpenter	Signed	(1) The employer does not elect the employers’ liability coverage.	Raymond Carpenter	corinnafrymoyer@gmail.com	Self	Tipton	Cedar	Iowa	Corinna frymoyer	Levi carpenter	Signed
1860	2023-10-04 14:31	Anonymous (not verified)	94.188.207.229	Raymond Osbon	Proprietorship	1634 Park Towne LN NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-04	Raymond Earl Osbon	rozbon999@gmail.com	Cedar Rapids	Linn	Iowa	Brandon Gibbs	Jamie Fisher	Signed	(1) The employer does not elect the employers’ liability coverage.	Raymond Earl Osbon	rozbon999@gmail.com	Myself	Cedar Rapids	Linn	Iowa	Brandon Gibbs	Jamie Fisher	Signed
827	2022-01-10 16:36	Anonymous (not verified)	167.142.141.89	Hill Lawn Care	Proprietorship	2307 Campbell Dr Marshalltown Iowa 50158	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-10	Raymond Hill	rayhill_19@hotmail.com	Marshalltown	Marshall	Iowa	Kaitlyn Schuring	Matt Gannaway	Signed	(1) The employer does not elect the employers’ liability coverage.	Raymond Hill	rayhill_19@hotmail.com	Self	Marshalltown	Marshall	Iowa	Kaitlyn Schuring	Matt Gannaway	Signed
25	2020-01-03 13:09	Anonymous (not verified)	74.84.121.206	Raymond Jones	Proprietorship	P O Box 682 Monona IA 52159	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.	2019-11-29	Raymond Jones	darrele@ciains.biz	Monona	Clayton	Iowa	Darrel J Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Darrel J Elsbernd	darrele@ciains.biz	insurance agent	Lime Springs	Howard	Iowa	Darrel J Elsbernd	Chris Fye	Signed
1491	2023-03-03 11:24	Anonymous (not verified)	94.188.207.224	Ray gist	Proprietorship	4330 nw 9th st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-03	Raymond Rex Gist	rrgist8@yahoo.com	Dsm	Polk	Ia	Amber Gist	Victor Brawdy	Signed	(1) The employer does not elect the employers’ liability coverage.	Raymond Rex Gist	rrgist8@yahoo.com	Same person	Dsm	Polk	Ia	Amber Gist	Victor Brawdy	Signed
66	2020-02-19 08:48	Anonymous (not verified)	170.232.227.246	CRS Inc	Proprietorship	1442 3rd Ave SW Belmond, IA 50421	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.	2020-02-19	Rebecca Gardner	beckygard1018@gmail.com	Waverly	Bremer	Iowa	Sarah Lowe	Kelsey Poe	Signed	(1) The employer does not elect the employers’ liability coverage.	Rebecca Gardner	beckygard1018@gmail.com	Consultant	Waverly	Bremer	Iowa	Sarah Lowe	Kelsey Poe	Signed
734	2021-11-11 14:05	Anonymous (not verified)	72.13.16.172	REDFEARN TRUCKING INC	Proprietorship	5512 WEST STAGECOACH TRAIL	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.	2019-11-18	REDFEARN TRUCKING INC	dave@allseasonstrucking.com	GALENA	JODAVIES	IL	DAVE NEUWOHNER	BEN MOYER	Signed	(1) The employer does not elect the employers’ liability coverage.	REDFEARN TRUCKING INC	dave@allseasonstrucking.com	PRESIDENT	GALENA	JODAVIES	IL	DAVE NEUWOHNER	BEN MOYER	Signed
1576	2023-04-17 08:32	Anonymous (not verified)	94.188.205.167	Reece Wilson	Limited Liability Company	1431 Starbeck Circle	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-14	Reece J Wilson	rjwilson030@gmail.com	Cedar Falls	Blackhawk	Iowa	Kendall Cotant	Darryl Mason	Signed	(1) The employer does not elect the employers’ liability coverage.	John Richter	jrichter@beecherlaw.com	Business	Waterloo	Blackhawk	Iowa	Kendall Cotant	Jared Hottle	Signed
1679	2023-06-06 08:27	Anonymous (not verified)	94.188.205.174	Remys Drywall LLC	Proprietorship	42 Hoover Blvd West Branch, IA 52358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-06	Remigio M Juan	remmateojuan1997@gmail.com	West Branch	Cedar	IA	Brad Bower	Chris Hay	Signed	(1) The employer does not elect the employers’ liability coverage.	Remigio M Juan	remmateojuan1997@gmail.com	Self	West Branch	Cedar	IA	Brad Bower	Chris Hay	Signed
1099	2022-05-13 12:17	Anonymous (not verified)	75.162.66.90	EMPIRE CONTRACTORS, LLC	Limited Liability Company	8415 FRANKLIN AVE APT 18 CLIVE, IOWA 50325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-13	RENE ALEXANDER VELASCO	velasco.alexander@yahoo.com	Des Moines	USA	Iowa	Yolanda Mendoza	Liliana Sanchez Gutierrez	Signed	(1) The employer does not elect the employers’ liability coverage.	RENE ALEXANDER VELASCO	velasco.alexander@yahoo.com	OWNER	DES MOINES	USA	IOWA	YOLANDA MENDOZA	LILIANA SANCHEZ GUTIERREZ	Signed
1102	2022-05-13 13:13	Anonymous (not verified)	75.162.173.244	EMPIRE CONTRACTORS, INC	Proprietorship	8415 FRANKLIN AVE APT 18 CLIVE, IOWA 50325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-13	RENE ALEXANDER VELASCO	velasco.alexander@yahoo.com	DES MOINES	USA	IOWA	YOLANDA MENDOZA	LILIANA SANCHEZ GUTIERREZ	Signed	(1) The employer does not elect the employers’ liability coverage.	RENE ALEXANDER VELASCO	velasco.alexander@yahoo.com	COMPANY OWNER	DES MOINES	USA	IOWA	YOLANDA MENDOZA	LILIANA SANCHEZ GUTIERREZ	Signed
1864	2023-10-09 09:52	Anonymous (not verified)	94.188.207.223	Admiral Staffing Inc	Limited Liability Company	580 8th Ave, 15th Floor, New York NY 10018	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.	2023-10-09	Rezwan Rafeek	ray@admiralstaffinginc.com	23 Catalpa Lane	Valley Stream	NY	Ikbal Sherif	Salim Balee	Signed	(1) The employer does not elect the employers’ liability coverage.	Shafi Rafeek	shafi@admiralstaffinginc.com	Office Manager	New York	NY	United States	Ikbal Sherif	Salin Balee	Signed
1826	2023-08-30 16:38	Anonymous (not verified)	94.188.207.227	IOWA MOLD REMOVAL	Limited Liability Company	103 15TH ST SW, ALTOONA, IA 50009	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-30	RHETT OSELETTE	RHETT.OSELETTE@GMAIL.COM	CLIVE	DALLAS	IOWA	ELLA OSELETTE	MYA OSELETTE	Signed	(1) The employer does not elect the employers’ liability coverage.	KATIE BROWN	KATIE@IOWAMOLDREMOVAL.COM	EMPLOYER	ALTOONA	POLK	IOWA	MYA OSELETTE	ELLA OSELETTE	Signed
1633	2023-05-09 15:46	Anonymous (not verified)	94.188.205.168	Unique Painting, LLC	Partnership	2500 E. 39Th Court	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.	2023-05-09	Ricardo Rodriguez Perfecto	uniquepainting00@gmail.com	Des Moines	USA	IOWA	Oseas Diaz	Jorge Corona	Signed	(1) The employer does not elect the employers’ liability coverage.	Ricardo Rodriguez Perfecto	uniquepainting00@gmail.com	Vice president	Des Moines	USA	IOWA	Oseas Diaz	Jorge Corona	Signed
1293	2022-09-03 08:03	Anonymous (not verified)	50.82.244.98	MTZ Drywall	Proprietorship	1101 Eighth St, West Des Moines, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-02	Richar Martinez	menace_42@icloud.com	West Des Moines	United States	Iowa	Alejandro Gonzalez	Emilio Martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Jerry Jenkins	jjenkins@farmersagent.com	N/A	Urbandale	United States	Iowa	Alejandro Gonzalez	Emilio Martinez	Signed
2145	2024-04-11 12:27	Anonymous (not verified)	94.188.205.177	Grinnell Web Services LLC	Limited Liability Company	1902 Spring St, Grinnell IA 50112	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.	2024-04-11	Richard Ethington	RDE326@rrmse.com	Grinnell	Poweshiek	Iowa	Lori Stratton	Lisa Folkmann	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard Ethington	rde326@rrmse.com	self	Grinnell	poweshiek	iowa	lori stratton	lisa folkmann	Signed
413	2021-02-24 16:21	Anonymous (not verified)	199.120.93.40	Nelson Tire Recycling LLC	Limited Liability Company	2270 Farley Rd Cascade Iowa 52033	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.	2021-02-24	Richard A Nelson	nelsontirerecycling@gmail.com	Cascade	Dubugue	Iowa	Wendy Bergfeld	Jan Elhinger	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Richard	nelsontirerecycling@gmail.com	Owner/officer	Cascade	Dubugue	Iowa	Wendy Bergfeld	Jan Ehlinger	Signed
1396	2022-12-19 18:35	Anonymous (not verified)	174.198.65.20	Flyover Productions LLC	Limited Liability Company	300 S Clinton St.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-19	Richard A Redfern	richredfern3@gmail.com	Iowa City	IA	United States	Susan Redfern	Aditi Reddy	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard Redfern	richredfern3@gmail.com	Owner of company	Iowa City	Iowa	United States	Susan Redfern	Aditi Reddy	Signed
2058	2024-02-26 16:32	Anonymous (not verified)	94.188.207.224	performance gutter	Proprietorship	PO BOX 306, 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.	2024-02-26	RICHARD BAINTER	RWBNJ50@AOL.COM	NORWALK	WARREN	IOWA	DYLAN LANE	JAMES LANE	Signed	(1) The employer does not elect the employers’ liability coverage.	RICHARD BAINTER	RWBNJ50@AOL.COM	OWNER	NORWALK	WARREN	IOWA	DYLAN LANE	JAMES LANE	Signed
1534	2023-03-27 08:16	Anonymous (not verified)	94.188.205.167	Richatd Deist	Proprietorship	1445 Hwy 71 Audubon IA 50025	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.	2023-03-26	Richard Deist	deistfarms@hotmail.com	Audubon	IA	United States	Tara Deist	Pat Groth	Signed	(1) The employer does not elect the employers’ liability coverage.	Bob Miller	bob.miller@millerhybrids.com	seed dealer	Kalona ,Ia	Washington	IA	Tara Deist	Pat Groth	Signed
1535	2023-03-27 09:40	Anonymous (not verified)	94.188.205.167	Richard Deist	Proprietorship	1445 hwy 71 Audubon Ia 50025	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.	2023-03-26	Richard Deist	deistfarms@hotmail.com	Audubon	Audubon	IA	Tara Deist	Pat Groth	Signed	(1) The employer does not elect the employers’ liability coverage.	Bob Miller	bob.miller@millerhybrids.com	Seed dealer	Kalona	Washington	IA	Tara Deist	Pat Groth	Signed
150	2020-05-06 10:59	Anonymous (not verified)	76.190.229.163	RNR Holdings LLC	Limited Liability Company	4330 Winter Eagle Trail SE Apt B, Iowa City, Iowa 52240	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.	2020-05-06	Richard E. White	rwhite245@yahoo.com	Hermitage	Mercer	Pennsylvania	Gene Bell	Victor J Veltri	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard E White	rwhite245@yahoo.com	Owner	Hermitage	Mercer	Pennsylvania	Gene Bell	Victor J Veltri	Signed
1045	2022-04-13 09:55	Anonymous (not verified)	192.119.237.126	BARGAIN HOUSE	Proprietorship	11 S FREDERICK AVE, OELWEIN, IA 50662	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.	2022-04-13	RICHARD M. BECKER	SHELBY@CIOIA.COM	HAZLETON	BUCHANAN	IOWA	SHELBY S. WILLIAMS	BOBBIE J. BERGAN	Signed	(1) The employer does not elect the employers’ liability coverage.	RICHARD M. BECKER	SHELBY@CIOIA.COM	OWNER	OELWEIN	FAYETTE	IOWA	SHELBY S. WILLIAMS	BOBBIE J. BERGAN	Signed
776	2021-12-03 10:26	Anonymous (not verified)	192.230.128.72	Richard Makohoniuk	Proprietorship	785 SE Walnut Ridge Dr Waukee, IA. 50263	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.	2021-12-03	Richard Makohoniuk	111@mchsi.com	Waukee	Dallas	Iowa	Tara Makohoniuk	Richard Makohoniuk	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard Makohoniuk	111@mchsi.com	Self	Waukee	Dallas	IA	Tara Makohoniuk	Richard Makohoniuk	Signed
1256	2022-08-15 13:22	Anonymous (not verified)	173.29.47.222	Premiere Plastering & Drywall, Inc.	Proprietorship	2331 W. 63rd St., Davenport, IA 52806	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-08-08	Richard Miller	rmiller0574@gmail.com	Davenport	Iowa	United States	Jamie Wardlow	Kandra Blumenshein	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Premiere Plastering & Drywall, Inc.	premiere_pd_llc@yahoo.com	Subcontractor	Davenport	Iowa	United States	Jamie Wardlow	Kandra Blumenshein	Signed
1028	2022-04-02 11:01	Anonymous (not verified)	174.198.64.100	Great-Dain Htg/Ac & Plumbing	Proprietorship	1616 Maple Rd. Harlan, Iowa 51537	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-02	Richard Nee	great-dain@hotmail.com	Harlan	Shelby	Iowa	Doug Clark	Jesse Nee	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard Nee	great-dain@hotmail.com	Self	Harlan	Shelby	Iowa	Doug Clark	Jesse Nee	Signed
856	2022-01-26 13:44	Anonymous (not verified)	69.63.16.2	Rick Peterson	Proprietorship	3366 Lynden Heights Rd NE, Iowa City IA 52240	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.	2022-01-26	Richard Peterson	insurancecommercialsam@greenstate.org	Iowa City	Johnson	Iowa	Jonathan Gonzalez	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Peterson	insurancecommercialsam@greenstate.org	Owner	Iowa City	Johnson	IA	Jonathan Gonzalez	Dyan Kriener	Signed
1425	2023-01-18 15:20	Anonymous (not verified)	174.228.35.74	Great-Dain Htg/Ac & Plumbing	Proprietorship	1616 Maple Rd Harlan, Iowa 51537	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-18	Richard Presly Nee	great-dain@hotmail.com	Harlan	Shelby	IA	Theresa Clark	Jesse Nee	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard Presley Nee	great-dain@hotmail.com	Self	Harlan	Shelby	IA	Theresa Clark	Jesse Nee	Signed
689	2021-10-25 14:38	Anonymous (not verified)	107.197.114.249	Brookstin Flooring LLC	Limited Liability Company	1702 Brown Deer Rd 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.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-10-25	Richard T Klemesrud	rickklemesrud@gmail.com	CORALVILLE	IA	United States	Brian Woods	Sherry Woods	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Richard T Klemesrud	rickklemesrud@gmail.com	Myself / Owner	CORALVILLE	IA	United States	Brian Woods	Sherry Woods	Signed
323	2020-11-19 10:55	Anonymous (not verified)	174.192.67.61	Connor trucking	Proprietorship	2791 270th st Dewitt ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-11-19	Richard Todd Connor	connortrucking@hotmail.com	Dewitt	Clinton	Iowa	Michelle Connor	Josh connor	Signed	(1) The employer does not elect the employers’ liability coverage.	Richard Todd Connor	connortruckin@hotmail.com	Self	Dewitt	Clinton	Iowa	Michelle Connor	Josh Connor	Signed
716	2021-11-05 13:22	Anonymous (not verified)	209.252.172.87	Rick Clifford Clifford Custom Tile & Flooring	Proprietorship	1563 Palmer Ct NE, Solon, IA 52333	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.	2020-09-24	Rick Clifford	cliffordcustomtile@gmail.com	Solon	Johnson	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Clifford Clifford Custom Tile & Flooring	cliffordcustomtile@gmail.com	Self Employed	Solon	Johnson	Iowa	Sarah Coberley	Heather Howell	Signed
562	2021-07-08 09:46	Anonymous (not verified)	66.188.136.150	Rick Davis	Proprietorship	521 N 13th St. Salina, KS 67401	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-07	Rick Davis	kschumacher@tricorinsurance.com	Salina	Saline	KS	Mitch Kemp	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Davis	kschumacher@tricorinsurance.com	Same	Salina	Saline	KS	Mitch Kemp	Shuree Behr	Signed
1930	2023-12-01 10:20	Anonymous (not verified)	94.188.207.227	TriCounty Enterprises/ DeNeve Construction	Limited Liability Company	5527 Crane Lane NE Cedar Rapids,IA 52402	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-01	Rick Delayne Primmer	rdprimmerroofing@gmail.com	Walker	Linn	Iowa	Jerry Wiltsey	Robert Null	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Delayne Primmer	rdprimmerroofing@gmail.com	Worker	Walker	Iowa	Iowa	Jerry Wiltsey	Robert Null	Signed
767	2021-11-22 16:42	Anonymous (not verified)	63.229.189.35	Lakes Custom Bath	Proprietorship	3721 Ithaca Avenue, 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.	2021-11-22	Rick Dykshoorn	abigail@rickmilesartisans.com	SPIRIT LAKE	Dickinson	Iowa	Abigail Miles	Alex Miles	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Dykshoorn	abigail@rickmilesartisans.com	Self	SPIRIT LAKE	Dickinson	Iowa	Abigail Miles	Alex Miles	Signed
720	2021-11-05 13:57	Anonymous (not verified)	209.252.172.87	Rick Klemesrud Brookstin Flooring	Proprietorship	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.	2020-05-23	Rick Klemesrud	installation@bachmeiercarpetone.com	Coralville	Johnson	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Klemesrud	installation@bachmeiercarpetone.com	Self	Croalville	Johnson	Iowa	Heather Howell	Sarah Coberley	Signed
918	2022-02-16 14:23	Anonymous (not verified)	172.58.22.152	RICK MYSAK LLC	Limited Liability Company	2220 GREY WOLF, HIAWATHA, IA 52233	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.	2022-02-16	RICK MYSAK	camysak@gmail.com	Hiawatha	LINN	IOWA	Carrie Mysak	RICK DeNEVE	Signed	(1) The employer does not elect the employers’ liability coverage.	RICK MYSAK	camysak@gmail.com	SELF	Hiawatha	LINN	IOWA	Carrie Mysak	RICK DeNEVE	Signed
1327	2022-10-06 12:23	Anonymous (not verified)	71.39.227.238	RICK OBEREMBT	Proprietorship	1702 SYCAMORE ST, DALLAS CNETER, 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.	2022-10-05	RICK OBEREMBT	werock83@gmail.com	DALLAS CENTER	DALLAS	IOWA	ABBEY LUELLEN	DON RICHARDSON	Signed	(1) The employer does not elect the employers’ liability coverage.	RICK OBEREMBT	werock83@gmail.com	SELF	DALLAS CENTER	DALLAS	IOWA	ABBEY LUELLEN	DON RICHARDSON	Signed
369	2021-01-22 10:02	Anonymous (not verified)	66.188.136.150	Rick Swaney	Proprietorship	1551 Persimmon, Stilwell, OK 74960	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-22	Rick Swaney	kschumacher@tricorinsurance.com	Stilwell	Adair	OK	Russell Masartis	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Rick Swaney	kschumacher@tricorinsurance.com	Same	Stilwell	Adair	OK	Russell Masartis	Shuree Behr	Signed

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