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:
1488	2023-02-28 14:04	Anonymous (not verified)	94.188.207.227	Scotts Side Work Plus	Limited Liability Company	304 Wilshire Blvd Windsor Heights IA 50324	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.	2023-02-28	Lansing Scott	scottssideworkplus@gmail.com	Windsor Heights	Iowa	United States	Collin scott	Austyn Scott	Signed	(1) The employer does not elect the employers’ liability coverage.	Lansing Scott	scottssideworkplus@gmail.com	owner	Windsor Heights	Iowa	United States	Austyn Scott	Tracy scott	Signed
578	2021-07-16 15:26	Anonymous (not verified)	184.80.177.137	Scotty's Appliance & TV, LLC	Limited Liability Company	529 5th St NW - Dyersville, IA 52040	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.	2021-07-16	Sandra Krogman	jheims@english-insurance.com	Dyersville	Dubuque	Iowa	Joyce Heims	Derrick Parsons	Signed	(1) The employer does not elect the employers’ liability coverage.	Derrick Parsons	jheims@english-insurance.com	agent	Dyersville	Dubuque	Iowa	Joyce Heims	Derrick Parsons	Signed
472	2021-04-13 10:58	Anonymous (not verified)	65.103.82.36	Scrap And More	Proprietorship	1303 W Linn St. Marshalltown, IA. 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.	2019-05-01	Travis Bachman	na@yahoo.com	marshalltown	marshall	IA	sarah	Tami	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Bachman	na@yahoo.com	owner	marshalltown	marsahll	IA	sara	tami	Signed
1492	2023-03-03 16:09	Anonymous (not verified)	94.188.207.229	Sean Aldrich LLC	Limited Liability Company	408 n.7th st. Indianola iowa 50125	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	Sean Kenneth Aldrich	sean.aldrich74@gmail.com	Indianola	Warren	Iowa	Madeline Jenelle Aldrich	John Thomas Aldrich	Signed	(1) The employer does not elect the employers’ liability coverage.	Sean Kenneth Aldrich	sean.aldrich74@gmail.com	Self	Indianola	Warren	Iowa	Madeline Jenelle Aldrich	John Thomas Aldrich	Signed
659	2021-09-28 11:02	Anonymous (not verified)	172.58.83.48	Sean Goodwin	Limited Liability Company	8843 primrose lane Clive IA 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.	2021-09-28	Sean Goodwin	simplemanmx@gmail.com	Clive	IA	United States	Kaitlyn meier	Tina meier	Signed	(1) The employer does not elect the employers’ liability coverage.	Sean Goodwin	simplemanmx@gmail.com	Self	Clive	Polk	Iowa	Kaitlyn meier	Tina meier	Signed
980	2022-03-16 09:38	Anonymous (not verified)	207.199.231.172	Sean Wursta	Proprietorship	401 Strawberry St Eddyville, IA 52553	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.	2022-03-16	Sean Wurstra	5wurstas@gmail.com	Eddyville	Mahaska	Iowa	James Anderson	Ashley Bryan	Signed	(1) The employer does not elect the employers’ liability coverage.	Self	5wurstas@gmail.com	self	Mahaska	Eddyville	Iowa	James Anderson	Ashley Bryan	Signed
1479	2023-02-24 08:34	Anonymous (not verified)	94.188.207.229	Sedenka Excavating and Habitat	Limited Liability Partnership	204 Meadowview Drive, Lisbon, IA 52253	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.	2023-02-24	Trey Sedenka	SedenkaEH@gmail.com	Lisbon	Cedar	Iowa	Robert Cummings	Jayson Wallace	Signed	(1) The employer does not elect the employers’ liability coverage.	Trey Sedenka	SedenkaEH@gmail.com	Owner	Lisbon	Cedar	Iowa	Robert Cummings	Jayson Wallace	Signed
1395	2022-12-15 08:02	Anonymous (not verified)	172.58.84.122	Sehic G&S, LCC	Limited Liability Company	4201 62nd st Urbandale iowa 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-15	Bajro sehic	kalesija20@gmail.com	Urbandale	Polk	Iowa	Bajro	Bajro	Signed	(1) The employer does not elect the employers’ liability coverage.	Bajro sehic	kalesija20@gmail.com	Owner	Urbandale	Dallas	Iowa	Bajro	Bajro	Signed
1384	2022-12-08 13:11	Anonymous (not verified)	172.58.81.43	Sehic G&S, LLC.	Limited Liability Company	4201 62nd st apt 4 Urbandale Ia 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-12-09	Bajro sehic	kalesija20@gmail.com	Urbandale	Polk	Iowa	N/A	N/A	Signed	(1) The employer does not elect the employers’ liability coverage.	Bajro sehic	kalesija20@gmail.com	Owner	Urbandale	Polk	Iowa	N/A	N/A	Signed
1014	2022-03-28 16:33	Anonymous (not verified)	76.102.203.170	Self - Maryssa Wanlass	Proprietorship	871 Wood St. Oakland CA 94607	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.	2021-01-01	Maryssa Wanlass	maryssa.wanlass@alli-center.com	Oakland	Alameda	California	Mark Vashro	Don Naughton	Signed	(1) The employer does not elect the employers’ liability coverage.	Maryssa Wanlass	maryssa.wanlass@alli-center.com	Self	Oakland	Alameda	California	Mark Vashro	Don Naughton	Signed
1591	2023-04-21 13:59	Anonymous (not verified)	94.188.207.226	Self employed	Proprietorship	406 s main prairie city	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.	2023-04-21	Thomas Leo carroll	Tom.carroll66@gmail.com	Prairie city	Jasper	Iowa	Tina hellyer	Matt wenthie	Signed	(1) The employer does not elect the employers’ liability coverage.	Tom carroll	Tom.carroll66@gmail.com	Self	Prairie city	Jasper	Iowa	Tina hellyer	Matt whinthy	Signed
2215	2024-05-08 22:07	Anonymous (not verified)	94.188.207.223	Self Employed-Ryan Thornton	Proprietorship	8403 Horton Ave Urbandale IA 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-08	Ryan M Thornton	rt6366155@gmail.com	Urbandale	Polk	Iowa	April Oxendale	Bruce Thornton	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Thornton	rt6366155@gmail.com	Self	Urbandale	Polk	Iowa	April Oxendale	Bruce Thornton	Signed
291	2020-10-25 11:06	Anonymous (not verified)	208.126.69.94	self-employed	Proprietorship	PO Box 15, 430 E. Iowa 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.	2022-10-25	Steven Fisher	fishersjk@gmail.com	St. Mary's	Iowa	United States	Jodi Fisher	Jenna Fisher	Signed	(1) The employer does not elect the employers’ liability coverage.	Steven Fisher	fishersjk@gmail.com	same person	St. Mary's	Iowa	United States	Jodi Fisher	Jenna Fisher	Signed
1010	2022-03-28 09:20	Anonymous (not verified)	173.21.74.26	Self-employed (Stacy Davids)	Proprietorship	35 Lynx Lane, North Liberty, IA 52317	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.	2022-03-28	Stacy Ann Davids	stacyanndavids@gmail.com	North Libery	Johsnons	IOWA	Darin Gylten	Zara Wanlass	Signed	(1) The employer does not elect the employers’ liability coverage.	Stacy Ann Davids	stacyanndavids@gmail.com	self	North Liberty	Johnson	Iowa	Darin Gylten	Zara Wanlass	Signed
1944	2023-12-06 16:41	Anonymous (not verified)	94.188.207.226	Sell Now Iowa	Limited Liability Company	5525 Meredith Dr Suite B Des Moines, Iowa 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-06	Alejandro Bacano Rodriguez	alejandrobacanorodriguez@gmail.com	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Sale Now Iowa	team@sellnowiowa.com	None	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed
1945	2023-12-06 16:47	Anonymous (not verified)	94.188.205.169	Sell Now Iowa	Limited Liability Company	5525 Meredith Drive Suite B Des Moines Iowa 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-06	Alejandro Bacano Rodriguez	alejandrobacanorodriguez@gmail.com	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed	(1) The employer does not elect the employers’ liability coverage.	Sell Now Iowa	team@sellnowiowa.com	None	Des Moines	Polk	Iowa	Breny Rodriguez	Gabriela Martinez	Signed
205	2020-07-15 14:19	Anonymous (not verified)	108.209.12.64	Sequoia integrative Medical Services	Limited Liability Company	1746 Paul Drive	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-15	Jennifer Christine VandenHeuvel	jvandenheuvel@att.net	Kaukauna	WI	United States	David VandenHeuvel	Pam Leplavy	Signed	(1) The employer does not elect the employers’ liability coverage.	Jennifer Christine VandenHeuvel	jvandenheuvel@att.net	Owner	Kaukauna	WI	United States	David VandenHeuvel	Pam Leplavy	Signed
208	2020-07-16 20:24	Anonymous (not verified)	216.127.193.93	Sequoia Integrative Medical Services	Limited Liability Company	W2560 Birschbach Drive, Mount Calvary, WI, 53057	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-16	Chad Weston Gardner	chadwestongardner@yahoo.com	Mount Calvary	Fond du Lac	Wisconsin	Emily Lucht	Ron Carpenter	Signed	(1) The employer does not elect the employers’ liability coverage.	Chad Weston Gardner	chadwestongardner@yahoo.com	Self	Mount Calvary	Fond du Lac	Wisconsin	Emily Lucht	Ron Carpenter	Signed
213	2020-07-21 17:47	Anonymous (not verified)	107.77.206.41	Sequoia integrative medical services	Limited Liability Company	W2560 birschbach drive, mount Calvary, WI 53057	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-16	Mary Kate friess	mkfriess71@gmail.com	Fond du lac	Fond du lac	WI	Gordon Lewis	Ron carpenter	Signed	(1) The employer does not elect the employers’ liability coverage.	Mary Kate friess	mkfriess71@gmail.com	Self	Fond du lac	Fond du lac	Wi	Gordon Lewis	Ron carpenter	Signed
2152	2024-04-15 17:23	Anonymous (not verified)	94.188.207.230	ServiceMaster by Harris	Proprietorship	432 Locust Street Waterloo, IA 50701	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.	2024-04-15	Joel Harris	joel.harris@forbin.net	Waterloo	IA	IA	None	None	Signed	(1) The employer does not elect the employers’ liability coverage.	Joel Harris	joel.harris@forbin.net	Owner	Waterloo	IA	IA	None	None	Signed
1628	2023-05-09 08:00	Anonymous (not verified)	94.188.205.175	Servin Drywall	Proprietorship	6311 Underwood 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.	2023-05-09	Arcel Servin	arcelservin77@gmail.com	Cedar Rapids	Linn	Iowa	Rolandas Bitanas	Kirk Strunk	Signed	(1) The employer does not elect the employers’ liability coverage.	Arcel Servin	arcelservin77@gmail.com	Self	Cedar Rapids	Linn	Iowa	Rolandas Bitanas	Kirk Strunk	Signed
278	2020-10-09 11:25	Anonymous (not verified)	174.243.82.229	ServTwelve7 Consulting, LLC	Limited Liability Company	1903 Elmhurst Avenue Humboldt, IA 50548	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.	2020-10-09	Sonya Satern	Sonya.satern@ServTwelve7.com	Humboldt	Humboldt	Iowa	Cindy Vik	Jill Westre	Signed	(1) The employer does not elect the employers’ liability coverage.	Sonya Satern	Sonya.Satern@ServTwelve7.com	self	Humboldt	Humboldt	Iowa	Cindy Vik	Jill Westre	Signed
1174	2022-06-28 07:53	Anonymous (not verified)	70.39.7.208	SG Solid Grounds	Proprietorship	402 3rd Ave SE State Center Iowa 50247	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.	2022-06-27	Stephen Graham	sgsolidgrounds@gmail.com	STATE CENTER	IA	United States	Stacie Graha	Paula Atkinson	Signed	(1) The employer does not elect the employers’ liability coverage.	Stephen Graham	sgsolidgrounds@gmail.com	Owner	STATE CENTER	IA	United States	Stacie Graham	Paula Atkinson	Signed
389	2021-02-10 13:59	Anonymous (not verified)	173.24.190.134	Shamrock Lanes, LLC	Limited Liability Company	1304 Broadway, PO Box 304, Emmetsburg IA 50536	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-03	Cindy Flannegan	cindylou1964@hotmail.com	Emmetsburg	Palo Alto	Iowa	Michael Flannegan	Laura Sidles	Signed	(1) The employer does not elect the employers’ liability coverage.	Cindy Flannegan	cindylou1964@hotmail.com	Member of LLC	Emmetsburg	Palo Alto	Iowa	Michael Flannegan	Laura Sidles	Signed
1896	2023-11-03 14:23	Anonymous (not verified)	94.188.207.225	Shane Adams	Limited Liability Company	3944 54th st Des Moines,IA 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-03	Shane Steven Adams	Shane6079@gmail.com	Des Moines	Polk	Iowa	Justin Mace	Denice Sutton	Signed	(1) The employer does not elect the employers’ liability coverage.	Shane Adams	Shane6079@gmail.com	Owner	Des Moines	Polk	Iowa	Justin Mace	Denice Sutton	Signed
497	2021-04-27 09:25	Anonymous (not verified)	204.153.176.147	SHANE HUCK	Proprietorship	1070 305TH STREET, NASHUA, IOWA 50658	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.	2021-04-27	SHANE HUCK	WOODHUCK@GMAIL.COM	NASHUA	CHICKASAW	IOWA	KIM LOECKLE	RACHEL SCHNEIDER	Signed	(1) The employer does not elect the employers’ liability coverage.	SHANE HUCK	WOODHUCK@GMAIL.COM	OWNER	NASHUA	CHICKASAW	IOWA	KIM LOECKLE	RACHEL SCHNEIDER	Signed
636	2021-09-10 14:56	Anonymous (not verified)	173.19.179.111	SHANNON SUNDINE	Proprietorship	513 16TH ST SPIRIT LAKE IA 51360	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-10	SHANNON SUNDINE	SPSUNDINE@GMAIL.COM	SPIRIT LAKE	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNG WIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	SHANNON SUNDINE	SPSUNDINE@GMAIL.COM	SELF	SPIRIT LAKE	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed
957	2022-03-08 14:54	Anonymous (not verified)	71.39.227.238	Sharol Williams	Proprietorship	1605 Ash 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.	2022-03-08	Sharol Williams	sharolann48@gmail.com	Dallas Center	Dallas	Iowa	Abbey Luellen	Steve Phillips	Signed	(1) The employer does not elect the employers’ liability coverage.	Sharol Williams	SharolAnn48@gmail.com	Self	Dallas Center	Dallas	Iowa	Abbey Luellen	Steve Phillips	Signed
549	2021-06-25 16:19	Anonymous (not verified)	165.225.57.46	Shaw Livestock, LLC	Limited Liability Company	6871 275th Street, Moravia, IA 52571-8003	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.	2021-06-25	Steven H. Shaw	steve@shawlivestock.com	Moravia	Appanoose	Iowa	Scott Saveraid	Alexa Sheeder	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Steven Shaw	steve@shawlivestock.com	Self	Moravia	Appanoose	Iowa	Scott Saveraid	Alexa Sheeder	Signed
550	2021-06-25 16:20	Anonymous (not verified)	165.225.61.18	Shaw Livestock, LLC	Limited Liability Company	6871 275th Street, Moravia, IA 52571-8003	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.	2021-06-25	Nathan Shaw	nate@shawlivestock.com	Moravia	Appanoose	Iowa	Scott Saveraid	Alexa Sheeder	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Nathan Shaw	nate@shawlivestock.com	Self	Moravia	Appanoose	Iowa	Scott Saveraid	Alexa Sheeder	Signed
753	2021-11-17 22:09	Anonymous (not verified)	107.77.219.76	Shaw Livestock, LLC.	Limited Liability Company	6871 275th Street, Moravia, IA 52571-8003	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.	2021-11-17	Nathan Nash Shaw	nathan@shawlivestock.com	Moravia	Monroe	Iowa	Scott Saveraid	Sandra Blindauer	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Nathan Shaw	nathan@shawlivestock.com	Self	Moravia	Monroe	Iowa	Scott Saveraid	Sandra Blindauer	Signed
1086	2022-05-03 12:32	Anonymous (not verified)	173.31.148.43	SHAWN BAIRD	Proprietorship	PO BOX 44 307 MEADOW ST ROYAL, IA 51357	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.	2022-05-02	SHAWN BAIRD	FLOORMAN3872@GMAIL.COM	ROYAL	CLAY	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	SHAWN BAIRD	FLOORMAN3872@GMAIL.COM	SELF	ROYAL	CLAY	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed
1965	2023-12-22 10:23	Anonymous (not verified)	94.188.207.229	Shawn Cooney	Proprietorship	4425 Ne 34th Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-22	Shawn Nelson Cooney	shawncooney59@gmail.com	Des Moines	polk	IA	Marie Cooney	Shawntel Cooney	Signed	(1) The employer does not elect the employers’ liability coverage.	Shawn Cooney	shawncooney59@gmail.com	Myself	Des Moines	polk	IA	Marie Cooney	Shawntel Cooney	Signed
223	2020-08-05 13:22	Anonymous (not verified)	173.28.28.57	Shear Beautique Retail, LLC	Limited Liability Company	910 Parriott, Aplington IA 50604	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-28	Lindsey Poppens	cmins_re@mchsi.com	Allison	BUTLER	Iowa	Thomas R Poppens	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Lindsey Poppens	cmins_re@mchsi.com	Self	Allison	Butler	Iowa	Thomas R Poppens	Roxanne Kolder	Signed
224	2020-08-05 13:25	Anonymous (not verified)	173.28.28.57	Shear Beautique Retail, LLC	Limited Liability Company	910 Parriott, Aplington IA 50604	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-28	Rachel Poppens	cmins_re@mchsi.com	Allison	Butler	Iowa	Thomas R Poppens	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Rachel Poppens	cmins_re@mchsi.com	Self	Allison	Butler	Iowa	Thomas R Poppens	Roxanne Kolder	Signed
362	2021-01-14 12:15	Anonymous (not verified)	173.26.157.255	Shear Bliss Pet Salon	Limited Liability Company	824 Ansborough Ave. Waterloo, IA 50701	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.	2021-01-14	Sarah K Bebee	shearblisspet@aol.com	Hudson	Black Hawk	Iowa	Janice Rae Bebee	Danny J Bebee	Signed	(1) The employer does not elect the employers’ liability coverage.	Sarah Bebee	shearblisspet@aol.com	self	Hudson	Black Hawk	Iowa	Janice Rae Bebee	Danny J Bebee	Signed
363	2021-01-14 12:17	Anonymous (not verified)	173.26.157.255	Shear Bliss Pet Salon	Limited Liability Company	824 Ansborough Ave. Waterloo, IA 50701	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.	2021-01-14	Melissa Kay Herold	shearblisspet@aol.com	Cedar Falls	Black Hawk	Iowa	Janice Rae Bebee	Danny J Bebee	Signed	(1) The employer does not elect the employers’ liability coverage.	Meliss Kay Herold	shearblisspet@aol.com	self	Cedar Falls	Black Hawk	Iowa	Janice Rae Bebee	Danny J Bebee	Signed
908	2022-02-09 15:06	Anonymous (not verified)	63.152.66.183	Shear Texture	Limited Liability Company	1427 A Ave NW	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	Wendy Kiser	kiser187@msn.com	Cedar Rapids	Linn	Iowa	Shelly Wehr	Kimberly Erickson	Signed	(1) The employer does not elect the employers’ liability coverage.	Wendy Kiser	kiser187@msn.com	Self	Cedar Rapids	Linn	Iowa	Shelly Wehr	Kimberly Erickson	Signed
1480	2023-02-24 08:54	Anonymous (not verified)	94.188.205.176	Shear Texture	Limited Liability Company	2000 Wiley Blvd 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.	2023-02-24	Wendy Kiser	kiser187@msn.com	Cedar Rapids	Linn	Iowa	Kim Erickson	Shauna Whitaker	Signed	(1) The employer does not elect the employers’ liability coverage.	Wendy Kiser	kiser187@msn.com	Self	Cedar Rapids	Linn	Iowa	Kim Erickson	Shauna Whitaker	Signed
2087	2024-03-11 09:39	Anonymous (not verified)	94.188.205.175	Shear Texture	Limited Liability Company	2000 Wiley Blvd 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.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2024-03-11	Wendy Kiser	kiser187@msn.com	Cedar Rapids	Linn	Iowa	Kim Erickson	Shauna Whitaker	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Wendy Kiser	kiser187@msn.com	Self	Cedar Rapids	Linn	Iowa	Kim Erickson	Shauna Whitaker	Signed
1184	2022-07-06 15:10	Anonymous (not verified)	149.20.238.108	Shelby County Fair Corporation	Limited Liability Company	314 4th St. Harlan, IA 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.	2022-05-06	Kaylee Goshorn	shelbycountyfair@fmctc.com	Harlan	Shelby	iowa	Kate Heese	Katie Petersen	Signed	(1) The employer does not elect the employers’ liability coverage.	Kaylee Goshorn	shelbycountyfair@fmctc.com	Board Member	Harlan	Shelby	Iowa	Kate Heese	Katie Petersen	Signed
1185	2022-07-06 15:12	Anonymous (not verified)	149.20.238.108	Shelby County Fair Corporation	Limited Liability Company	314 4th St. Harlan, IA 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.	2022-05-06	Darren Goshorn	shelbycountyfair@fmctc.com	Harlan	Shelby	Iowa	Kate Heese	Katie Petersen	Signed	(1) The employer does not elect the employers’ liability coverage.	Darren Goshorn	shelbycountyfair@fmctc.com	Board Member	Harlan	Shelby	IA	Kate Heese	Katie Petersen	Signed
1186	2022-07-06 15:49	Anonymous (not verified)	149.20.238.108	Shelby County Fair Corporation	Limited Liability Company	314 4th St., Harlan, IA 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.	2022-05-06	Lee Schoof	shelbycountyfair@fmctc.com	Harlan	Shelby	Iowa	Kate Heese	Katie Petersen	Signed	(1) The employer does not elect the employers’ liability coverage.	Lee Schoof	shelbycountyfair@fmctc.com	Board Member	harlan	Shelby	Iowa	Kate Heese	Katie Petersen	Signed
1187	2022-07-06 15:51	Anonymous (not verified)	149.20.238.108	Shelby County Fair Corporation	Limited Liability Company	314 4th St. Harlan, IA 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.	2022-05-06	Kyle Manz	shelbycountyfair@fmctc.com	Harlan	Shelby	Iowa	Kate Heese	Katie Petersen	Signed	(1) The employer does not elect the employers’ liability coverage.	Kyle Manz	shelbycountyfair@fmctc.com	Board Member	Harlan	Shelby	Iowa	Kate Heese	Katie Petersen	Signed
2091	2024-03-12 15:23	Anonymous (not verified)	94.188.205.166	Shelley onnen	Proprietorship	1319 West 2nd Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-12	Shelley L Onnen	Shelleyonnen47@gmail.com	PERRY	IA	United States	Matthew Dean Rote	Jerica Renae Wiborg	Signed	(1) The employer does not elect the employers’ liability coverage.	Shelley L Onnen	Shelleyonnen47@gmail.com	Self	PERRY	IA	United States	Matthew Dean Rote	Jerica Renae Wiborg	Signed
343	2020-12-28 10:46	Anonymous (not verified)	173.18.204.82	Shelly Hildebrand	Proprietorship	424 E 44th St Pleasant Hill Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-12-28	Shelly Hildebrand	centraliowacleaningservice@mediacombb.net	Pleasant Hill	Polk	Iowa	Cathy Stevens	Bailey Hildebrand	Signed	(1) The employer does not elect the employers’ liability coverage.	Shelly Hildebrand	centraliowacleaningservice@mediacombb.net	Self	Pleasant Hill	Polk	Iowa	Cathy Stevens	Bailey Hildebrand	Signed
155	2020-05-12 17:03	Anonymous (not verified)	173.17.184.241	Shelly Whalen	Proprietorship	1625 Darby Dr Waterloo IA 50702	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-12	Shelly Whalen	swhalen90@hotmail.com	Waterloo	IA	United States	Taylor Whalen	Todd Gerleman	Signed	(1) The employer does not elect the employers’ liability coverage.	Shelly Whalen	swhalen90@hotmail.com	self employed	Waterloo	IA	United States	Taylor Whalen	Todd Gerleman	Signed
509	2021-05-10 15:25	Anonymous (not verified)	108.190.5.14	Shift Transport LLC	Limited Liability Company	4215 Kris Line Drive Waterloo, IA 50701	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.	2021-05-10	Damir Pajazetovic	damirp2015@gmail.com	Waterloo	Black Hawk	Iowa	Fata Pajazetovic	Melda Pajazetovic	Signed	(1) The employer does not elect the employers’ liability coverage.	Adnan Pajazetovic	adoni.shift@gmail.com	Owner	Waterloo	Black Hawk	Iowa	Fata Pajazetovic	Melda Pajazetovic	Signed
510	2021-05-10 15:27	Anonymous (not verified)	108.190.5.14	Shift Transport LLC	Limited Liability Company	4215 Kris Line 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.	2021-05-10	Adnan Pajazetovic	Adoni.shift@gmail.com	Waterloo	Black Hawk	Iowa	Fata Pajazetovic	Melda Pajazetovic	Signed	(1) The employer does not elect the employers’ liability coverage.	Adnan Pajazetovic	adoni.shift@gmail.com	Owner	Waterloo	Black Hawk	Iowa	Fata Pajazetovic	Melda Pajazetovic	Signed
36	2020-01-15 13:26	Anonymous (not verified)	173.28.28.57	Shirley Pepples	Proprietorship	206 4th Street, Parkersburg, IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-14	Shirley Pepples	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Shirley Pepples	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed

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