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:
662	2021-10-01 16:05	Anonymous (not verified)	174.242.224.18	Troy bryan	Limited Liability Company	2800 68th 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.	2021-10-01	Troy bryan	tbryan0015@gmail.com	Urbandale	Polk	Iowa	Brenna painter	Marc bryan	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Troy bryan	tbryan0015@gmail.com	Owner	Urbandale	Polk	Iowa	Brenna painter	Marc bryan	Signed
1837	2023-09-11 19:10	Anonymous (not verified)	94.188.207.230	TBA Handyman service	Limited Liability Company	619 e 10th st. north newton Iowa 50208	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.	2023-09-11	Joey Conkling	tba050402@gmail.com	newton	jasper	Iowa	Ashton tyler conkling	Bianca Storm Conkling	Signed	(1) The employer does not elect the employers’ liability coverage.	TBA Handyman Service	tbaconstruction02@gmail.com	self	newton	jasper	iowa	Ashton tyler Conkling	Bianca Storm Conkling	Signed
387	2021-02-08 14:26	Anonymous (not verified)	192.30.185.142	Go 2 Girls	Proprietorship	104 Doral Lane, Dakota Dunes, SD 57049	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.	2021-02-08	Tawnya Oneill	tawny5881@gmail.com	Dakota Dunes	Union	SD	Katie Jenks	Virginia Anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Tawnya Oneill	tawny5881@gmail.com	Owner	Dakota Dunes	Union	SD	Katie Jenks	Virginia Anderson	Signed
761	2021-11-22 07:22	Anonymous (not verified)	73.211.163.27	James crockett	Limited Liability Company	417 easr st south Kewanee il 61443	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-22	James crockett	tattoojec@gmail.com	Kewanee il	Henery	Il	Tom mcintire	Colton english	Signed	(1) The employer does not elect the employers’ liability coverage.	Hog city construction	tattoojec@gmail.com	Self	Kewanee	Henery	Il	Tom mcintire	Colon english	Signed
393	2021-02-11 12:36	Anonymous (not verified)	173.21.130.224	Ashby Roofing	Proprietorship	3307 Clearwater dr Bettendorf	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.	2021-02-11	Thomas Ashby	Tashby8@aol.com	Bettendorf	Scott	Iowa	Veronica Ashby	Tommy Ashby	Signed	(1) The employer does not elect the employers’ liability coverage.	United Insurance Counslers	Tashby8@aol.com	owner	Bettendorf	Scott	Iowa	Veronica Ashby	Tommy Ashby	Signed
679	2021-10-18 13:14	Anonymous (not verified)	173.18.22.217	Xscape Extreme Hard & Landscape	Proprietorship	3215 E 25th CT Bldg 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.	2021-10-18	Mike Tapper	Tapper4981@gmail.com	Des Moines	Polk	IA	Lesa Dillon	Kelly Coluzzi	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Tapp	Tapper4981@gmail.com	Owner	Des Moines	Des Moines	IA	Lesa Dillon	Kelly Coluzzi	Signed
724	2021-11-05 14:25	Anonymous (not verified)	209.252.172.87	Josh Peterson	Proprietorship	121 Karen Drive, Williamsburg, IA 52361	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-15	Josh Peterson	tanyataz@msn.com	Williamsburg	Iowa	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Peterson	tanyataz@msn.com	Self Employed	Williamsburg	Iowa	Iowa	Sarah Coberley	Heather Howell	Signed
426	2021-03-09 09:31	Anonymous (not verified)	50.82.173.179	Joshua Strong DBA Watson Excavation	Proprietorship	202 Lewis St Bedford, IA 50833	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.	2021-03-09	Joshua Strong	joshandtanyastrong@yahoo.com	Bedford	Taylor	IA	Maggie Jackson	Shella Baldwin	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Tanya Strong	tanya@farmandhomellc.com	Spouse	Bedford	IA	United States	Maggie Jackson	Shella Baldwin	Signed
1495	2023-03-06 09:57	Anonymous (not verified)	94.188.207.224	Midwest Indoor Air Quality, LLC	Limited Liability Company	701 NE Brook Haven Drive, Ankeny, IA 50021	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.	2023-03-06	Tanner Evan Francisco	tanner.midwestindoorairquality@outlook.com	Ankeny	IA	United States	Sherry Reynolds	David Boyer	Signed	(1) The employer does not elect the employers’ liability coverage.	Midwest Indoor Air Quality, LLC	tanner.midwestindoorairquality@outlook.com	Same	Ankeny	IA	United States	Sherry Reynolds	David Boyer	Signed
464	2021-04-07 22:15	Anonymous (not verified)	173.18.251.105	TEMPLEMAN LAWN CARE AND SNOW REMOVAL	Proprietorship	1612 Lomas Circle	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-07	TIM LEE Templeman	nancytempleman@gmail.com	Atlantic	IA	United States	TARA JESSEN	ALFRED WEDE	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	CULLEN AND ASSOCIATES	tammy@cullenins.com	Insurance agent	Atlantic	Cass	Iowa	Tara Jessen	Alfred Wede	Signed
144	2020-04-29 11:20	Anonymous (not verified)	65.158.103.107	Symbiotic Gardens LLC	Limited Liability Company	3403 Dubuque Avenue Des Moines Iowa 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-29	Brandon Kam	symbioticgardens@gmail.com	Des Moines	Polk	Iowa	Kathy Schulte	Larry Johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandon Kam	symbioticgardens@gmail.com	same	Des Moines	Polk	Iowa	Kathy Schulte	Larry Johnson	Signed
727	2021-11-05 14:46	Anonymous (not verified)	174.198.66.202	Bret Swift Swift Enterprises	Proprietorship	2240 Coldstream Drive NE, Cedar Rapids, Ia 52402	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-13	Brett Swidt	swiftenterprises@me.com	Cedar Rapids	Linn	Iowa	Sarah Coberley	Heather Howell	Signed	(1) The employer does not elect the employers’ liability coverage.	Bret Swift	swiftenterprises@me.com	Self Employed	Cedar Rapids	Linn	Iowa	Sarah Coberley	Heather Howell	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
1197	2022-07-11 08:35	Anonymous (not verified)	107.127.35.22	Leaf Filter	Limited Liability Partnership	3060 SE Grimes Blvd	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.	2022-07-11	Jacqueline Martínez	charamusca05erick@icloud.com	West Des Moines	United Stated	Iowa	Melvin Gomez	Martín Martínez	Signed	(1) The employer does not elect the employers’ liability coverage.	Leaf Filter	support@leafhome.com	Sub contractor	Grimes	United States	Iowa	Melvin Gomez	Martín Martínez	Signed
1315	2022-09-20 13:11	Anonymous (not verified)	173.17.128.203	Leaffilter	Proprietorship	1595 Georgetown Rd., Hudson, OH 44236	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.	2022-09-20	Johnny Coker	johnnycoker36@gmail.com	Altoona	Polk	Iowa	Travis Klapproth	Emilie Klapproth	Signed	(1) The employer does not elect the employers’ liability coverage.	LeafFilter	support@leafhome.com	Sub contractor	Grimes	Polk	Iowa	Travis Klapproth	Emilie Klapproth	Signed
1833	2023-09-08 13:39	Anonymous (not verified)	94.188.207.225	Superior painting & epoxy coatings llc	Limited Liability Company	4918 ne crestmoor ln	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-05	Anthony Negrete jr	superior.paint@hotmail.com	Ankeny	IA	United States	Stacey Marie stoecker	Anthony Negrete jr.	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony Negrete jr	superior.paint@hotmail.com	Spouse	Ankeny	IA	United States	Anthony Negrete jr	stacey marie Stoecker	Signed
1367	2022-11-11 11:06	Anonymous (not verified)	173.29.231.17	Sosa Flooring	Proprietorship	2310 NE 16TH Ankeny, Iowa 50021	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-11	Zeferino Alcantara Sosa	sunnysosa@aol.com	Ankeny	Polk	Iowa	Ashley Temple	Sunny Sosa	Signed	(1) The employer does not elect the employers’ liability coverage.	Zeferino Alcantara Sosa	sunnysosa@aol.com	OWNER	Ankeny	Polk	Iowa	Ashley Temple	Sunny Sosa	Signed
829	2022-01-11 11:03	Anonymous (not verified)	173.22.78.156	Marr Arnold Planning, LLC	Limited Liability Company	1328 California Ave, Ames, IA 50014	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.	2022-01-11	Summer Marr	summer@marrarnoldplanning.com	Ames	Story	IA	Beth Skluzacek	Kris Evans	Signed	(1) The employer does not elect the employers’ liability coverage.	Summer Marr	summer@marrarnoldplanning.com	owner	Ames	Story	IA	Beth Skluzacek	Kris Evans	Signed
1654	2023-05-19 11:09	Anonymous (not verified)	94.188.205.176	ST SULLIVAN CONSTRUCTION COMPANY	Proprietorship	1614 100TH ST., OELWEIN, IOWA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-19	STEVE SULLIVAN	sullycon@msn.com	Oelwein	Fayette	Iowa	Bobbie J Bergan	Shelby Williams	Signed	(1) The employer does not elect the employers’ liability coverage.	STEVE SULLIVAN	sullycon@msn.com	OWNER	OELWEIN	FAYETTE	IOWA	BOBBIE J BERGAN	SHELBY WILLIAMS	Signed
237	2020-08-18 19:01	Anonymous (not verified)	174.125.150.45	Wdflyers llc	Limited Liability Company	453 hwy 1183 Simmesport la 71369	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.	2020-07-25	Donald Anderson	sugarscoot@yahoo.com	Simmesport	Avoyelles	Louisiana	kolter coco	wendy coco	Signed	(1) The employer does not elect the employers’ liability coverage.	Donald Anderson	sugarscoot@yahoo.com	self	Simmesport	Avoyelles	Louisiana	kolter coco	wendy coco	Signed
341	2020-12-23 08:52	Anonymous (not verified)	174.243.82.219	Jason D Struchen	Proprietorship	1778 210th St Webster City, IA 50595	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-23	Jason David Struchen	steruchen75@gmail.com	Webster City	Hamilton	Iowa	NA	NA	Signed	(1) The employer does not elect the employers’ liability coverage.	Jason D Struchen	struchen75@gmail.com	Same	Webster City	Hamilton	Iowa	NA	NA	Signed
2026	2024-02-07 08:32	Anonymous (not verified)	94.188.205.169	Strong Fencing & Decking LLC	Limited Liability Company	343 59th Street 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.	2024-02-07	Jacob James Strong	strongfencingdecking@gmail.com	Des Moines	Polk	Iowa	Paige Crowley	Jacob Waugh	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob Strong	strongfencingdecking@gmail.com	Owner	Des Moines	Polk	Iowa	Paige Crowley	Jacob Waugh	Signed
1643	2023-05-12 07:56	Anonymous (not verified)	94.188.205.169	Smooth Finish Drywall	Proprietorship	3111 115th Riverside, IA 52327	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.	2023-05-12	Seth T Mize II	stmize@hotmail.com	Riverside	Washington	Iowa	Chris Hay	Brad Bower	Signed	(1) The employer does not elect the employers’ liability coverage.	Seth T Mize II	stmize@hotmail.com	Self	Riverside	Washington	Iowa	Chris Hay	Brad Bower	Signed
1644	2023-05-12 07:59	Anonymous (not verified)	94.188.205.176	Blue Ribbon Drywall	Proprietorship	3025 Peaceful Dr Riverside, IA 52327	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.	2023-05-12	Seth Mize Sr	stmize@hotmail.com	Riverside	Washington	Iowa	Brad Bower	Chris Hay	Signed	(1) The employer does not elect the employers’ liability coverage.	Seth Mize Sr	stmize@hotmail.com	Self	Riverside	Washington	Iowa	Brad Bower	Chris Hay	Signed
1782	2023-08-04 08:04	Anonymous (not verified)	94.188.207.229	Matt Larson Construction	Limited Liability Company	1208 Hazel St. Pella, IA 50219	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.	2023-08-04	Matthew Mark Larson	larson-m@hotmail.com	Pella	Marion	IA	Brian Huddle	Jon E. Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Jon E. Miller	stmarypella@iowatelecom.net	Parish Secretary	Pella	IOWA	United States	Brian Huddle	Jon E. Miller	Signed
1072	2022-04-26 16:17	Anonymous (not verified)	166.182.80.187	N & S Trucking Inc	Limited Liability Company	3061 170Th 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.	2022-04-26	Steven Kirk Van Ommen	Stevevo74@yahoo.com	Riverside	Iowa	United States	Steve Van Ommen	Steve Van Ommen	Signed	(1) The employer does not elect the employers’ liability coverage.	Steven Kirk Van Ommen	Stevevo74@yahoo.com	President	Riverside	IA	United States	Steve Van Ommen	Steve Van Ommen	Signed
422	2021-03-05 13:53	Anonymous (not verified)	71.39.227.238	Steven 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.	2021-03-06	Steven Phillips	stevep@phillipsassociatesins.net	Linden	Guthrie	Iowa	Abbey Luellen	RoseMary Phillips	Signed	(1) The employer does not elect the employers’ liability coverage.	Steven Phillips	stevep@phillipsassociatesins.net	Self	Linden	Guthrie	Iowa	RoseMary Phillips	Abbey Luellen	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
1399	2022-12-22 08:40	Anonymous (not verified)	45.16.156.93	Valley Five, LLC DBA L & N Docks and Lifts	Limited Liability Company	9523 W 151st Ter Overland Park, KS 66221	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.	2022-12-22	Steven Dolezal	steven.w.dolezal@gmail.com	Overland Park	Johnson	Kansas	Joan Dolezal	Kelsey Dolezal	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Dolezal	steven.w.dolezal@gmail.com	Owner	Overland Park	Johnson	Kansas	Joan Dolezal	Kelsey Dolezal	Signed
207	2020-07-16 13:05	Anonymous (not verified)	173.16.140.254	Steve Kennedy	Proprietorship	5108 SW 13th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-16	Steve Kennedy	stevekennedy@gmail.com	Des Moines	Polk	Iowa	Jen Echterling	Jake Hibbert	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Kennedy	stevekennedy007@gmail.com	Owner	Des Moines	Polk	Iowa	Jen Echterling	Jake Hibbert	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
31	2020-01-07 08:37	Anonymous (not verified)	199.10.5.7	Data Information Management LLC	Limited Liability Company	703 Bluff St Dubuque IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-07	Christopher R Broessel	chris@caricomm.com	Dubuque	Dubuque	IA	Janet L Schauff	Morris P Schauff	Signed	(1) The employer does not elect the employers’ liability coverage.	Stephen M schauff	steve@caricomm.com	Partner	Dubuque IA	Dubuque	Iowa	Janet L schauff	Morris P Schauff	Signed
1466	2023-02-17 15:12	Anonymous (not verified)	94.188.207.230	BIG Roofing, LLC	Limited Liability Company	5751 NE 22nd St. #304 Des Moines, IA 50313	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-17	Tyler Jeffrey Baugh	tj@bigroofing515.com	Lincoln	Lancaster	Nebraska	Steven Bieghler	Andrew John Kohles	Signed	(1) The employer does not elect the employers’ liability coverage.	Steven Craig Bieghler	steve@bigroofing515.com	Owner	Cumming	Dallas	Iowa	Tyler Jeffrey Baugh	Andrew John Kohles	Signed
1170	2022-06-24 08:52	Anonymous (not verified)	66.255.230.24	Anderson's Flying Service	Proprietorship	PO Box 127 Robbins, CA 95676	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.	2022-06-24	Stephen Anderson	steve@andersonsflying.com	YUBA CITY	CA	United States	Greg Foster	Cliff Snelling	Signed	(1) The employer does not elect the employers’ liability coverage.	Stephen Anderson	steve@andersonsflying.com	Self	YUBA CITY	CA	United States	Greg Foster	Cliff Snelling	Signed
864	2022-01-27 12:50	Anonymous (not verified)	67.55.155.207	Chamra Farms	Limited Liability Company	3031 215 th 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.	2022-01-01	Andy Chamra	apchamra@gmail.com	Rose Hill	Iowa	United States	Steve Weller	Connie VanKlootwyk	Signed	(1) The employer does not elect the employers’ liability coverage.	Steven Weller	steve.weller@insurancestationinc.com	Agent	OSKALOOSA	Iowa	United States	Andy Chamra	Connie Van Klootwyk	Signed
865	2022-01-27 12:53	Anonymous (not verified)	67.55.155.207	Chamra Farms	Limited Liability Company	3031 215 th 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.	2022-01-01	Roy Chamra	apchamra@gmail.com	Rose Hill	Iowa	United States	Steven Weller	Connie VanKlootwyk	Signed	(1) The employer does not elect the employers’ liability coverage.	Steven Weller	steve.weller@insurancestationinc.com	Agent	OSKALOOSA	Iowa	United States	Roy Chamra	Connie Van Klootwyk	Signed
1471	2023-02-20 10:24	Anonymous (not verified)	94.188.205.169	Vega Investments	Limited Liability Company	330 NE 72nd Street, Pleasant Hill, IA 50327	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-20	Stephanie Westrom	stephanie.westrom@microsoft.com	Pleasant Hill	Polk	Iowa	Thomas Westrom	Jean Schnake	Signed	(1) The employer does not elect the employers’ liability coverage.	Stephanie Westrom	stephanie.westrom@microsoft.com	Owner	Pleasant Hill	Polk	Iowa	Thomas Westrom	Jean Schnake	Signed
2180	2024-04-25 14:19	Anonymous (not verified)	94.188.205.169	Stems Flower Shop, LLC	Limited Liability Company	515 8th St SE	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.	2024-04-22	Stephanie Groom	stephanie.groom@stemsiowa.com	Altoona	Polk	Iowa	Kelli Kerton	Tyler Ingle	Signed	(1) The employer does not elect the employers’ liability coverage.	Stephanie Groom	stephanie.groom@stemsiowa.com	Self - Business Owner	Altoona	Polk	Iowa	Kelli Kerton	Tyler Ingle	Signed
1730	2023-07-09 23:39	Anonymous (not verified)	94.188.207.225	Steffens Constuction	Proprietorship	68222 Lansing Road, Wiota, IA 50274	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.	2023-07-07	Bradyn Richard Steffens	steffens4211@gmail.com	Wiota	Cass	Iowa	Katrina Sonntag	Chris Obrien	Signed	(1) The employer does not elect the employers’ liability coverage.	Audra Kelley Steffens	steffens4211@gmail.com	wife	Wiota	Cass	Iowa	Katrina Sonntag	Chris Obrien	Signed
820	2022-01-03 10:41	Anonymous (not verified)	174.195.193.112	Wolverine Construction LLC	Limited Liability Company	467 s 84th 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.	2022-01-03	steffan sheehey	steffanrobert@gmail.com	West Des Moines	Dallas	IA	Christopher Sheehey	Taylor Lyman	Signed	(1) The employer does not elect the employers’ liability coverage.	steffan sheehey	steffanrobert@gmail.com	Manager	West Des Moines	Dallas	IA	Christopher Sheehey	Marcus Hatcher	Signed
1432	2023-01-25 16:52	Anonymous (not verified)	174.228.33.48	Thermal Tight Insulators	Proprietorship	1331 Linden Road	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.	2023-01-25	Shawn Carter	steelershawn@gmail.com	Harlan	Iowa	United States	Barbara Carter	McKenzie carter	Signed	(1) The employer does not elect the employers’ liability coverage.	Shawn Carter	steelershawn@gmail.com	Self	Harlan	Iowa	United States	Barbara Carter	McKenzie carter	Signed
488	2021-04-20 13:42	Anonymous (not verified)	69.63.16.2	STC Construction LLC	Limited Liability Company	329 Sycamore St, Riverside, IA 52327	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.	2021-04-20	Sean Crane	stc0241@gmail.com	Riverside	Washington	Iowa	Carol Glass	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Sean Crane	stc0241@gmail.com	Managing Member	Riverside	Washingon	Iowa	Carol Glass	Dyan Kriener	Signed
1382	2022-12-07 14:40	Anonymous (not verified)	96.31.1.206	IGL RENTAL LLC	Limited Liability Company	PO BOX 317	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	AARON JONES	STAYBOJI@GMAIL.COM	ARNOLDS PARK	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	AARON JONES	STAYBOJI@GMAIL.COM	SELF	ARNOLDS PARK	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed
1383	2022-12-07 14:42	Anonymous (not verified)	96.31.1.206	IGL RENTAL LLC	Limited Liability Company	PO BOX 317 ARNOLDS PARK IA 51331	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	CHAD JONES	STAYBOJI@GMAIL.COM	ARNOLDS PARK	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	CHAD JONES	STAYBOJI@GMAIL.COM	SELF	ARNOLDS PARK	DICKINSON	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed
1417	2023-01-11 08:55	Anonymous (not verified)	174.235.209.245	Standard Insulation Company, LLC	Limited Liability Company	1066 Prairieview Ave., Van Meter, IA 50261	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.	2023-01-11	Mitchell Simonson	standard.insulation@outlook.com	Van Meter	Madison	IA	Jeremy Smith	Sue Sherman	Signed	(1) The employer does not elect the employers’ liability coverage.	Mitchell Simonson	standard.insulation@outlook.com	Owner	Van Meter	Madison	IA	Jeremy Smith	Sue Sherman	Signed
926	2022-02-17 15:20	Anonymous (not verified)	166.181.83.68	Staley Trucking LLC	Limited Liability Company	1388 140th 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.	2022-02-17	Travis Staley	staleyracing121@gmail.com	Hampton	Franklin	IA	Tyler Staley	Jeff Staley	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Staley	staleyracing121@gmail.com	President	Hampton	Franklin	IA	Tyler Staley	Jeff Staley	Signed
728	2021-11-05 14:52	Anonymous (not verified)	209.252.172.87	Stacy Wade Wade Flooring Specialist	Proprietorship	2481 247th St, Washington, IA 52353	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-15	Stacy Wade	stacywade92@gmail.com	Washington	Washington	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Stacy Wade	stacywade92@gmail.com	Self	Washington	Washington	Iowa	Sarah Coberley	Heather Howell	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
1769	2023-07-31 11:23	Anonymous (not verified)	94.188.207.228	PSI LLC	Limited Liability Company	2765 N Center Point Rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-31	Esteici Reyes	stacy0979@gmail.com	Cedar Rapids	Linn	IA	Jeffrey Ventura	Eduardo Contreras	Signed	(1) The employer does not elect the employers’ liability coverage.	Esteici Reyes	stacy0979@gmail.com	Owner	Cedar Rapids	Linn	IA	Jeffrey Ventura	Eduardo Contreras	Signed
1908	2023-11-15 10:59	Anonymous (not verified)	94.188.207.230	Snelling Construction, LLC	Limited Liability Company	309 Railroad Ave. Tripoli, IA 50676	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-15	Spencer W. Snelling	ssnell71@yahoo.com	Tripoili	Bremer	Iowa	Michael Meyer	Shawn Pipho	Signed	(1) The employer does not elect the employers’ liability coverage.	Spencer W. Snelling	ssnell71@yahoo.com	same	Tripoli	Bremer	Iowa	Michael Meyer	Shawn Pipho	Signed

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