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:
1224	2022-07-23 14:14	Anonymous (not verified)	69.57.205.10	Robert W. Cantrell	Proprietorship	845 East Redwood Circle, Hanford, CA 93230	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-23	Robert Wescott Cantrell	marquisaviationinc@yahoo.com	Hanford	Kings	CA	Shirley J. Loney	Joel L. Meyer	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Westcott Cantrell	marquisaviationinc@yahoo.com	proprietor	Hanford	Kings	CA	Shirley J. Loney	Joel L. Meyer	Signed
1269	2022-08-18 16:17	Anonymous (not verified)	67.55.174.140	Roberts Compliance Services, LLC	Limited Liability Company	405 Hilltop Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-18	Daniel Roberts	dan@robertscompliance.com	Stanton	Montgomery	IA	Robert Schenck	Pier Osweiler	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Roberts	dan@robertscompliance.com	self	Stanton	Montgomery	IA	Robert Schenck	Pier Osweiler	Signed
501	2021-04-29 15:47	Anonymous (not verified)	184.179.6.93	Rodney Bohannon	Proprietorship	5221 Crogans Way Rd, Council Bluffs IA 51501	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-29	Rodney Bohannon	bohannonrod@gmail.com	Council Bluffs	POTTAWATTAMIE	iowa	KIMBERLY L ARFMAN	Tami Cull	Signed	(1) The employer does not elect the employers’ liability coverage.	Rodney Bohannon	bohannonrod@gmail.com	Owner	Council Bluffs	POTTAWATTAMIE	IA	KIMBERLY L ARFMAN	Tami Cull	Signed
1061	2022-04-19 19:30	Anonymous (not verified)	172.58.83.52	Rodolfo Perez	Proprietorship	3420 E 12th St Des Moines Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-19	Rodolfo Perez	Elgordo0738@gmail.com	Des Moines	Polk	Iowa	Henry santos	Larry ramos	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Lantz	Info@lantzelite.com	Self employed no workers	Urbandale	Polk	Iowa	Henry santos	Larry ramos	Signed
403	2021-02-16 11:20	Anonymous (not verified)	192.30.185.142	Rodrigo Ochoa	Proprietorship	3310 5th St, Sioux City, IA 51105	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.	2021-02-16	Rodrigo Ochoa	jesusochoa1976@icloud.com	Sioux City	Woodbury	IA	Katie Jenks	Jenni Ebner	Signed	(1) The employer does not elect the employers’ liability coverage.	Rodrigo Ochoa	jesusochoa1976@icloud.com	Owner	Sioux City	Woodbury	IA	Katie Jenks	Jenni Ebner	Signed
1910	2023-11-15 13:06	Anonymous (not verified)	94.188.207.228	RODRIGUEZ ENTERPRISES III INC	Limited Liability Company	905 W US HIGHWAY 30 CARROLL IA 51401	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.	2023-11-14	MAURO RODRIGUEZ	mauro15o1@hotmail.com	CARROLL	CARROLL	IOWA	GONZALO MUNOZ	SILVIA CHAVEZ	Signed	(1) The employer does not elect the employers’ liability coverage.	MAURO RODRIGUEZ	mauro15o1@hotmail.com	OWNER	CARROLL	CARROLL	IA	GONZALO MUNOZ	SILVIA CHAVEZ	Signed
2207	2024-05-07 09:44	Anonymous (not verified)	94.188.207.226	Rodrimart brothers corp	Limited Liability Company	958 8th ave nw Altoona 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.	2024-05-07	Enrique Rodriguez	carluto_1983@hotmail.com	Altoona	Polk	Iowa	Adan boge	Lonce wester	Signed	(1) The employer does not elect the employers’ liability coverage.	Enrique Rodriguez	carluto_1983@hotmail.com	President	Altoona	Polk	Iowa	Adan boge	Leans wester	Signed
877	2022-01-31 11:43	Anonymous (not verified)	75.162.226.236	Rogelio De La rosa	Proprietorship	2104 E 25th St. 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.	2022-01-31	Rogelio De La rosa jr	chucotx@rocketmail.com	Des Moines	polk	Ia	Noreen Henry	Christian Lopez	Signed	(1) The employer does not elect the employers’ liability coverage.	Rogelio De La Rosa	chucotx@rocketmail.com	owner	Des moines	polk	Ia	Noreen Henry	Christian Lopez	Signed
611	2021-08-19 15:23	Anonymous (not verified)	97.125.53.119	Rogelio Lopez Casillas	Proprietorship	1175 Office Park Road Apt 109 WDM, Iowa 50265	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-21	Rogelio Lopez Casillas	deb@piciowa.com	West Des Moines	Polk	Iowa	Debra Stratton	Kelly K Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Rogelio Lopez Casillas	deb@piciowa.com	subcontractor	West Des Moines	Polk	Iowa	Debra Stratton	Kelly K Denger	Signed
285	2020-10-21 16:24	Anonymous (not verified)	66.188.136.150	Roger Cole	Proprietorship	30 Devon Dr. Dubuque, IA 52001	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-21	Roger cole	kschumacher@tricorinsurance.com	Dubuque	Dubuque	IA	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	Roger Cole	kschumacher@tricorinsurance.com	Same	Dubuque	Dubuque	IA	Russell Masartis	Nancy Wortley	Signed
898	2022-02-04 21:46	Anonymous (not verified)	107.77.161.27	Roger De La Rosa	Proprietorship	2104 E 25th St Des Moines IA 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-04	Roger De La Rosa	roger_dlr72@yahoo.com	Des Moines	Polk	IA	Noreen Henry	Christian Lopez	Signed	(1) The employer does not elect the employers’ liability coverage.	Roger De La Rosa	roger_dlr72@yahoo.com	Owner	Des Moines	Polk	IA	Noreen Henry	Christian Lopez	Signed
451	2021-03-25 17:00	Anonymous (not verified)	166.181.80.120	Rogers conc,. const,	Partnership	220804 CO, RD, ANAMOSA IA, 52205	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-25	Alex olah	aolah43@gmail.com	Cedar Rapids	Linn	Iowa	Robin marie kane	Augie rodreguez	Signed	(1) The employer does not elect the employers’ liability coverage.	Kevin johnson	kevinecollins@libertymutual.com	Ins , Agent	Appleton	Dane	Wisconsin	Robin marie kane	Augie Rodriguez	Signed
452	2021-03-26 07:30	Anonymous (not verified)	173.31.109.49	Rogers Concrete Construction	Partnership	22802 County Rd E34	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-26	Alexander Olah	aolah43@gmail.com	Cedar Rapids	Linn	Iowa	Robin Marie Kane	Augies Rodrigez	Signed	(1) The employer does not elect the employers’ liability coverage.	Kevin Johnson	kevinjohnson@libertymutual.com	Insurance Agent	Appleton	Outagamie	Wisconsin	Robin Marie Kane	Augie Rodrigez	Signed
743	2021-11-11 15:19	Anonymous (not verified)	72.13.16.172	ROLING TRANSPORT LLC	Limited Liability Company	33041 395TH AVENUE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-11-18	ROLING TRUCKING LLC	dave@allseasonstrucking.com	BELLEVUE	JACKSON	IA	Dave Neuwohner	BEN MOYER	Signed	(1) The employer does not elect the employers’ liability coverage.	ROLING TRUCKING LLC	dave@allseasonstrucking.com	PRESIDENT	BELLEVUE	JACKSON	IA	Dave Neuwohner	BEN MOYER	Signed
406	2021-02-18 10:41	Anonymous (not verified)	165.225.61.119	Romeo Painitng	Proprietorship	7 Waverly Dr Rock Island, IL 61201	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.	2021-02-18	Jay Romeo	jay.romeo12@yahoo.com	Rock Island	Rock Island	IL	Seth Rowland	Ryan Myers	Signed	(1) The employer does not elect the employers’ liability coverage.	Jay Romeo	jay.romeo12@yahoo.com	Self	Rock island	Rock Island	IL	Seth Rowland	Ryan Myers	Signed
1731	2023-07-10 11:12	Anonymous (not verified)	94.188.207.228	Romer & Associates LLC	Limited Liability Company	433 Thomas Avenue, Maquoketa, IA 52060	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.	2023-07-10	Clay K Romer	connellsupply@aol.com	Maquoketa	Jackson	IA	Susan Croatt	Dave Stockham	Signed	(1) The employer does not elect the employers’ liability coverage.	Clay K Romer	connellsupply@aol.com	Owner/same	Maquoketa	Jackson	IA	Susan Croatt	Dave Stockham	Signed
443	2021-03-22 13:22	Anonymous (not verified)	167.127.218.244	Romero Carpentry	Proprietorship	2060 King Ave, Apt 19, Des Moines, IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-22	Jose Wilber Romero Batres	Josew.batres@icloud.com	Des moines	Polk	United States	Gabriela Cecibel Chicas	David Antonio Barrera Serrano	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Wilber Romero Batres	Josew.batres@icloud.com	Self	Des Moines	Polk	Iowa	Gabriela Cecibel Chicas	David Antonio Barrera Serrano	Signed
1688	2023-06-13 09:29	Anonymous (not verified)	94.188.207.228	Ron Burbach	Proprietorship	7760 commerce park Dubuque Iowa 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.	2023-06-13	Ronald V Burbach	allgreenron@msn.com	Dubuque	Dubuqie	Iowa	Mia Burnach	Jerry david	Signed	(1) The employer does not elect the employers’ liability coverage.	Ronald V Burbach	allgreenron@man.com	Same	Dubuque	Dubuque	Iowa	Mia F Burbach	Jerry David	Signed
1781	2023-08-03 21:23	Anonymous (not verified)	94.188.205.166	Ron Peiffer Machine	Limited Liability Company	139 S 1st St Harpers Ferry, Ia 52146	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.	2023-08-03	Ron Peiffer	ron@rpeiffer.com	Harpers Ferry	Allamakee	Iowa	Marie Burington	Cassie Bakke	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron Peiffer	ron@rpeiffer.com	myself- SOLE PROPRIETOR	Harpers Ferry	Allamakee	Iowa	Marie Burington	Cassie Bakke	Signed
276	2020-10-08 12:55	Anonymous (not verified)	65.103.82.36	Ron Ray	Limited Liability Company	311 N Division Creston Iowa 50801	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.	2020-10-08	Ron L Ray	641-782-0521@gmail.com	Creston	Union	Iowa	Kayla Artioli	Eric Johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron L Ray	641-782-0521@gmail.com	Self	Creston	Union	Iowa	Kayla Artioli	Eric Johnson	Signed
521	2021-05-17 14:23	Anonymous (not verified)	66.188.136.150	Ron Wagner	Proprietorship	602 1/2 Ave G Apt. 5 Ft. Madison, IA 52627	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.	2021-05-17	Ron Wagner	kschumacher@tricorinsurance.com	Ft. Madison	Lee	IA	Jordan Bass	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron Wagner	kschumacher@tricorinsurance.com	Same	Ft. Madison	Lee	IA	Jordan Bass	Shuree Behr	Signed
1882	2023-10-27 10:40	Anonymous (not verified)	94.188.205.166	Ron's SIding and Construction	Proprietorship	6097 26th 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.	2025-02-02	Ron Heggebo	heggebojessica@yahoo.com	Vinton	Benton	IA	Jessica Heggebo	Jessica Heggebo	Signed	(1) The employer does not elect the employers’ liability coverage.	Ronnie Heggebo	heggebojessica@yahoo.com	self	Vinton	Benton	IA	Jessica Heggebo	Jessica Heggebo	Signed
1883	2023-10-27 10:49	Anonymous (not verified)	94.188.207.228	Ron's SIding and Construction	Proprietorship	6097 26th 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.	2023-10-27	Ron Heggebo	heggebojessica@yahoo.com	Vinton	Benton	IA	Jessica Heggebo	Jessica Heggebo	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron Heggebo	heggebojessica@yahoo.com	Self	Vinton	Benton	IA	Jessica Heggebo	Jessica Heggebo	Signed
332	2020-12-04 10:57	Anonymous (not verified)	66.188.136.150	Ron's Trucking LLC	Limited Liability Company	16007 Oak Avenue, Oak Forrest, IL 60452	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.	2020-12-04	Ronald Clark Jr.	kschumacher@tricorinsurance.com	Oak Forrest	Cook	IL	Russell Masartis	Nancy Wortley	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron's Trucking LLC	kschumacher@tricorinsurance.com	Same	Oak Forrest	Cook	IL	Russell Masartis	Nancy Wortley	Signed
1153	2022-06-13 16:22	Anonymous (not verified)	216.9.166.5	Ronald B Blakley	Proprietorship	2001 St Bridgets Rd 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.	2022-06-08	Ronald B Blakley	sanjahunt@gmail.com	Solon	Johnson	Iowa	Scott G Freeman	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Ronald B Blakley	Sanjahunt@gmail.com	Owner	Solon	Johnson	Iowa	Scott G Freeman	Dyan Kriener	Signed
1151	2022-06-13 09:29	Anonymous (not verified)	208.126.52.58	Ronald D. Heneke	Proprietorship	PO Box 114	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.	2022-06-13	Ronald D. Heneke	rheneke@email.com	Delmar	Clinton	Iowa	Mary S. O’Dell	Neal J. Damm	Signed	(1) The employer does not elect the employers’ liability coverage.	Ronald D. Heneke	rheneke@email.com	Self	Delmar	Clinton	Iowa	Mary S. O’Dell	Neal J. Damm	Signed
1630	2023-05-09 08:54	Anonymous (not verified)	94.188.207.225	Ronald McChane	Proprietorship	400 Lewellen dr nw, CEDAR RAPIDS, IA 52405, 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.	2023-05-09	Ronald McChane	rws79213@gmail.com	Cedar Rapids	Linn	Iowa	Jordan Nisiewicz	Charles Woods	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Iowa	Charles Woods	Jordan Loyd	Signed
427	2021-03-10 11:52	Anonymous (not verified)	66.188.136.150	Ronald Tessen	Proprietorship	493 Hill St. Green Lake, WI 54941	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-10	Ronald Tessen	kschumacher@tricorinsurance.com	Green Lake	Green Lake	WI	Russell Masartis	Amanda Seeberger	Signed	(1) The employer does not elect the employers’ liability coverage.	Ronald Tessen	kschumacher@tricorinsurance.com	Same	Green Lake	Green Lake	WI	Russell Masartis	Amanda Seeberger	Signed
1968	2023-12-28 14:57	Anonymous (not verified)	94.188.205.175	Rose Frimpong	Proprietorship	2110 NW 31st St. Ankeny, IA 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.	2023-12-28	Rose Frimprong	domena69@hotmail.com	Ankeny	Polk	Iowa	Amabilis Ngwa	Chris Abonge	Signed	(1) The employer does not elect the employers’ liability coverage.	Rose Frimpong	domena69@hotmail.com	Self-employed	Ankeny	Polk	Iowa	Chris Abonge	Amabilis Ngwa	Signed
423	2021-03-05 13:55	Anonymous (not verified)	71.39.227.238	RoseMary Phillips	Proprietorship	1107 Walnut St, Dallas Center, IA 50063	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-05	RoseMary Phillips	stevep@phillipsassociatesins.net	Linden	Guthrie	Iowa	Steven Phillips	Abbey Luellen	Signed	(1) The employer does not elect the employers’ liability coverage.	RoseMary Phillips	stevep@phillipsassociatesins.net	Self	Linden	Guthrie	Iowa	Steve Phillips	Abbey Luellen	Signed
1843	2023-09-14 14:12	Anonymous (not verified)	94.188.205.167	Rosenbum Construction, LLC	Limited Liability Company	720 South Street, Arlington, Iowa 50606	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	Thomas Rosenbum	tomdolly1126@yahoo.com	Arlington	Fayette	Iowa	Dolly Rosenbum	Steve Frost	Signed	(1) The employer does not elect the employers’ liability coverage.	Thomas Rosenbum	tomdolly1126@yahoo.com	Self	Arlington	Fayette	Iowa	Dolly Rosenbum	Steve Frost	Signed
1659	2023-05-23 13:39	Anonymous (not verified)	94.188.205.168	Rosendo Mora	Proprietorship	222 E Webster Street, Goldfield IA 50542	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.	2022-05-16	Rosendo Mora	office.seamlesspros@icloud.com	Goldfield	Wright	Iowa	Anthony Buck	Troy Knutson	Signed	(1) The employer does not elect the employers’ liability coverage.	Rosendo Mora	office.seamlesspros@icloud.com	Self	Goldfield	Wright	Iowa	Anthony Buck	Troy Knutson	Signed
14	2019-12-30 17:22	Anonymous (not verified)	173.20.51.69	Rotten Love LLC	Limited Liability Company	1101 Valentine Drive, Dubuque Iowa 52003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-01-01	john rettenmeier	jrettenmeier@gmail.com	dubuque	Dubuque	iowa	Carolyn Schmid	Joe Rettenmeier	Signed	(1) The employer does not elect the employers’ liability coverage.	Carolyn Schmid	jrettenmeier@gmail.com	owner	Dubuque	Dubuque	iowa	John Rettenmeier	John Rettenmeier	Signed
824	2022-01-06 20:57	Anonymous (not verified)	209.252.175.92	Rottweiler Remodel & Repair LLC	Limited Liability Company	1503 10th Ave Sw 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.	2022-01-06	Zechariah Robert DeLaVergne	rottweilerremodel@gmail.com	Cedar Rapids	Linn County	Iowa	Kathy Maxine Morgan	Daisha Rae Gonzalez	Signed	(1) The employer does not elect the employers’ liability coverage.	Zechariah DeLaVergne	rottweilerremodel@gmail.com	Owner	Cedar Rapids	Linn County	Iowa	Kathy Maxine Morgan	daisha rae gonzalez	Signed
1827	2023-09-01 15:45	Anonymous (not verified)	94.188.205.166	Roush construction	Proprietorship	Roush construction (self)	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.	2023-09-01	Jontie Steven roush	natycady@hotmail.com	Indianola	Warren	Iowa	Tara murphy	Mike ryerson	Signed	(1) The employer does not elect the employers’ liability coverage.	Jontie Steven roush	natycady@hotmail.com	Same person.	Indianola	Warren	Iowa	Tara murphy	Mike ryerson	Signed
891	2022-02-03 15:25	Anonymous (not verified)	173.23.180.117	Roy Dawson	Proprietorship	2602 Green Creek, 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.	2022-02-03	Roy Dawson	roydawson19@gmail.com	Cedar Falls	Black Hawk County	Iowa	Nickole Pry	Christine Willis	Signed	(1) The employer does not elect the employers’ liability coverage.	Roy Dawson	roydawson19@gmail.com	Same person	Cedar Falls	Black Hawk	Iowa	Nickole Pry	Christine Willis	Signed
1138	2022-06-01 15:01	Anonymous (not verified)	173.18.233.175	Roy Rohwedder	Proprietorship	296 24th Ave SW Cedar Rapids, IA 52404	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.	2022-06-01	Roy h Rohwedder	rohwedder.roy@yahoo.com	Cedar Rapids	linn	iowa	Cash Rohwedder	Brian Ashlock	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Ashlock	brian@tricounty-iowa.com	Genaral Manager	Cedar Rapids	Linn	IOWA	Branden Peters	Jenny Vaske	Signed
686	2021-10-20 18:43	Anonymous (not verified)	173.27.196.168	Royal Flooring	Proprietorship	11801 Hickman Rd Urbandale, IA 50323 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.	2021-10-20	Joel Cisneros	auroraramos476@gmail.com	Des Moines	Polk county	Iowa	Aurora Cisneros	Maria Arroyo	Signed	(1) The employer does not elect the employers’ liability coverage.	Royal Flooring	cisnerostile476@gmail.com	Employee	Clive	Dallas	Iowa	Aurora Cisneros	Maria Arroyo	Signed
1065	2022-04-21 16:26	Anonymous (not verified)	172.58.84.198	Royal Flooring	Limited Liability Company	11801 Hickman Rd Urbandale Iowa 50323	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.	2022-04-21	Alondra Canedo Orta	alondracanedo34@gmail.com	Des Moines	Polk county	Iowa	Alondra Canedo	Marvin Bonilla	Signed	(1) The employer does not elect the employers’ liability coverage.	Royal Flooring	Workorders@shoproyalflooring.com	Employee	Des Moines	Polk county	Iowa	Alondra Canedo	Marvin Bonilla	Signed
1844	2023-09-14 14:15	Anonymous (not verified)	94.188.205.177	Royal Gutters & Construction, LLC	Limited Liability Company	1420 120th Street, Hazleton, IA 50641	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.	2023-04-01	Andy Hershberger	hershbergera@gmail.com	Hazleton	Buchanan	Iowa	Eli Raber	Steve Frost	Signed	(1) The employer does not elect the employers’ liability coverage.	Andy Herschberger	hershbergera@gmail.com	self	Hazleton	Buchanan	Iowa	Eli Miller	Steve Frost	Signed
154	2020-05-12 15:00	Anonymous (not verified)	97.125.253.184	Rundle Creations	Limited Liability Company	5816 Urbandale Avenue, Des Moines, 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.	2020-05-12	Mark Lavern Rundle II	rundlecreations@gmail.com	Des Moines	Polk	Iowa	Luis Alex Jimenez	Jennifer Lea Griffith	Signed	(1) The employer does not elect the employers’ liability coverage.	Erika Anne Rundle	rundlecreations@gmail.com	Co-Owner	Des Moines	Polk	Iowa	Luis Alex Jimenez	Jennifer Lea Griffith	Signed
528	2021-05-21 14:06	Anonymous (not verified)	66.188.136.150	Russell Masartis	Proprietorship	481 Clarendon East Dubuque, IL 61025	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.	2021-05-21	Russell Masartis	kschumacher@tricorinsurance.com	East Dubuque	Jo Daviess	IL	Mitch Kemp	Shuree Behr	Signed	(1) The employer does not elect the employers’ liability coverage.	Russell Masartis	kschumacher@tricorinsurance.com	Same	East Dubuque	Jo Daviess	IL	Mitch Kemp	Shuree Behr	Signed
542	2021-06-16 07:26	Anonymous (not verified)	173.23.202.34	Russell’s lawn & landscape	Limited Liability Company	285 robins rd, Hiawatha unit C16	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.	2021-06-16	Johnoy Khalil Russell	johnoyjrrussell@gmail.com	Hiawatha	Linn	Iowa	Adrian pink	Rupert Ellis	Signed	(1) The employer does not elect the employers’ liability coverage.	Johnoy Khalil russell	johnoyjrrussell@gmail.com	Owner	Hiawatha	Linn	Iowa	Rupert ellis	Adrian pink	Signed
907	2022-02-09 08:59	Anonymous (not verified)	173.28.0.37	Rusty K5 LLC	Limited Liability Company	804 SW Cherry St Ankeny, IA 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.	2022-02-09	Kristy Briles	kristyabriles@gmail.com	Des Moines	Polk	IA	Stephanie Seymour	Sue Briles	Signed	(1) The employer does not elect the employers’ liability coverage.	Kristy Briles	kristyabriles@gmail.com	Owner	Des moines	Polk	IA	50313	Sue Briles	Signed
512	2021-05-11 13:12	Anonymous (not verified)	173.31.147.225	RUTHVEN ROCKS LLC	Limited Liability Company	1205 ROLLING ST RUTHVEN IOWA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-11	JEFF CACEK	JEFF@RUTHVENROCKS.COM	RUTHVEN	PALO ALTO	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	JEFF CACEK	joel@walkerinsuranceia.com	MEMBER	RUTHVEN	PALO ALTO	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
513	2021-05-11 13:14	Anonymous (not verified)	173.31.147.225	RUTHVEN ROCKS LLC	Limited Liability Company	1205 ROLLING ST RUTHVEN IOWA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-11	KEITH CACEK	KEITH@RUTHVENROCKS.COM	RUTHVEN	PALO ALTO	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	KEITH CACEK	joel@walkerinsuranceia.com	MEMBER	RUTHVEN	PALO ALTO	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
514	2021-05-11 13:16	Anonymous (not verified)	173.31.147.225	RUTHVEN ROCKS LLC	Limited Liability Company	1205 ROLLING ST RUTHVEN IOWA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-11	MATT CACEK	MATT@RUTHVENROCKS.COM	MILFORD	DICKINSON	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	MATT CACEK	joel@walkerinsuranceia.com	MEMBER	MILFORD	PALO ALTO	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1433	2023-01-27 13:24	Anonymous (not verified)	184.97.152.214	Rwdcarpet	Proprietorship	4927 cedarbrook 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.	2023-01-27	Robert Wayne Durand iii	rwdcarpet24@gmail.com	Council bluffs	Pottawattamie	Iowa	Kitty whissinand	Kelley durand	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Wayne Durand iii	rwdcarpet24@gmail.com	Self	Council bluffs	Pottawattamie	Iowa	Kitty whissinand	Kelley Durand	Signed
1624	2023-05-03 10:30	Anonymous (not verified)	94.188.207.227	Ryan Deymonaz	Proprietorship	2303 Kingsway 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.	2023-05-03	Ryan Deymonaz	ryan.deymonaz@gmail.com	Bettendorf	Iowa	United States	Ryan Deymonaz	Hannah Baker	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Deymonaz	ryan.deymonaz@gmail.com	Self	Bettendorf	Iowa	United States	Ryan Deymonaz	Hannah Baker	Signed
1004	2022-03-23 15:01	Anonymous (not verified)	104.201.110.2	Ryan Fischer	Proprietorship	809 8th St 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.	2022-03-23	Ryan Fischer	rfischer@phillipsstaffod.com	Des Moines	Polk	IA	Josh Stafford	Desiree Dennis	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Fischer	rfischer@phillipsstafford.com	Self	DES MOINES	IA	United States	Josh Stafford	Desiree Dennis	Signed

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