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:
1035	2022-04-05 12:03	Anonymous (not verified)	199.120.121.97	Bruce Peters Painting	Proprietorship	53568 Rosewood Road, Walnut IA 51577	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-05	Bruce Peters	bpeters1992@yahoo.com	Walnut	Pottawattamie	Iowa	Marie Peters	Angie Gettys	Signed	(1) The employer does not elect the employers’ liability coverage.	Bruce Peters	bpeters1992@yahoo.com	self	Walnut	Pottawattamie	Iowa	Marie Peters	Angie Gettys	Signed
2138	2024-04-05 12:30	Anonymous (not verified)	94.188.205.167	Joseph L Neighbors dba J L N Trucking	Proprietorship	5466 18th Ave Mount Auburn IA 52313	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.	2024-04-05	Joseph L Neighbors	robynne@cmbrown.net	Mount Auburn	Benton	Iowa	Sarah Svehla	Angela Vangennip	Signed	(1) The employer does not elect the employers’ liability coverage.	Robynne Dawn Duvall	robynne@cmbrown.net	insurance agent	Perryville	Missouri	Missouri	Sarah Svehla	Angela Vangennip	Signed
892	2022-02-03 15:52	Anonymous (not verified)	204.155.61.217	JD DRYWALL	Proprietorship	503 9th Street Kalona, Iowa 52247	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-03	John Duwa	johnduwa@outlook.com	Kalona	Washington	Iowa	Jeff Spenner	Angela Stutzman	Signed	(1) The employer does not elect the employers’ liability coverage.	JD Drywall - John Duwa	johnduwa@outlook.com	owner	Kalona	Washington	Iowa	Jeff Spenner	Angela Stutzman	Signed
1372	2022-11-14 20:36	Anonymous (not verified)	198.14.213.147	Accurate Grading, LLC	Limited Liability Company	1417 290th St Macksburg, IA 50155	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.	2022-11-14	Dustin A McVay	dustin0980@gmail.com	Macksburg	IA	United States	Dustin A McVay	Angela D McVay	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin A McVay	dustin0980@gmail.com	Owner	Macksburg	United States	Iowa	Dustin A McVay	Angela D McVay	Signed
381	2021-02-02 12:46	Anonymous (not verified)	167.142.150.21	T and A Transfer, LLC.	Limited Liability Company	3330 340th 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.	2021-02-02	Todd L Ahrenholtz	todd.ahrenholtz123@gmail.com	Manilla	IA	IA	Angela Ahrenholtz	Angela Ahrenholtz	Signed	(1) The employer does not elect the employers’ liability coverage.	Todd L Ahrenholtz	todd.ahrenholtz123@gmail.com	owner	Manilla	Iowa	Iowa	Angela Ahrenholtz	Angela Ahrenholtz	Signed
1849	2023-09-19 14:57	Anonymous (not verified)	94.188.207.228	Iowa painting solutions llc	Limited Liability Company	2500 pleasant st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-19	Patricia Davalos	iowapaintingsolutionsllc@gmail.com	Des Moines	Polk	Iowa	Javier Rascon	Angel Perez	Signed	(1) The employer does not elect the employers’ liability coverage.	Iowa painting solutions llc	iowapaintingsolutionsllc@gmail.com	Owner	Des Moines	Polk	Iowa	Javier Rascon	Angel Perez	Signed
1571	2023-04-13 10:30	Anonymous (not verified)	94.188.205.177	Pierick Enterprise 2	Limited Liability Company	806 6oth Ave	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-13	SAMUEL PIERICK	wirehairguids@gmail.com	Pleasantville	IA	United States	Kelly Wyckoff	Andy Wyckoff	Signed	(1) The employer does not elect the employers’ liability coverage.	SAMUEL PIERICK	wirehairguids@gmail.com	Member	Pleasantville	IA	United States	Kelly Wyckoff	Andy Wyckoff	Signed
583	2021-07-23 12:37	Anonymous (not verified)	206.72.45.27	S&L Finishers LLC	Limited Liability Company	307 N 5th Street Mallard Ia 50562	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.	2021-07-23	Luke AKRIDGE	akridgel@ncn.net	Mallard	Palo Alto	United States	Kennedy Origer	Andy Wiita	Signed	(1) The employer does not elect the employers’ liability coverage.	Luke AKRIDGE	akridgel@ncn.net	Owner	MALLARD	IA	United States	Kennedy Origer	Andy Wiita	Signed
1774	2023-08-03 08:40	Anonymous (not verified)	94.188.205.168	J P Trucking, Inc.	Proprietorship	8768 White Tail Lane, Dubuque, IA 52003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-03	Jamison Noel	jptrucking.jamison@gmail.com	Dubuque	DBQ	Iowa	Lindsay Noel	Andy Kemp	Signed	(1) The employer does not elect the employers’ liability coverage.	Jamison Noel	jptrucking.jamison@gmail.com	Owner	Dubuque	Dubuque	Iowa	Lindsay Noel	Andy Kemp	Signed
1277	2022-08-22 08:57	Anonymous (not verified)	68.169.247.177	Andrew Betts	Proprietorship	305 3rd ave sw cascade ia	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-22	Andrew Betts	dbidrywallco@gmail.com	Cascade	Dubuque	Iowa	Jamie manternach	Andy hall	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Betts	dbidrywallco@gmail.com	Owner	Cascade	Iowa	United States	Jamie manternach	Andy hall	Signed
1796	2023-08-13 13:35	Anonymous (not verified)	94.188.205.176	Mirsad Mulic	Limited Liability Company	7094 Hickory 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.	2023-08-13	Mirsad Mulic	finecarpentry30@icloud.com	Urbandale	Polk	IA	Peter Griffin	Andy Dufre	Signed	(1) The employer does not elect the employers’ liability coverage.	Fine Carpentry	finecarpentry30@icloud.com	Partner	Urbandale	Polk	IA	Griffin Peterson	Andy Dufre	Signed
2034	2024-02-07 11:58	Anonymous (not verified)	94.188.207.230	Bryce Abbott	Proprietorship	114 West Linn Street, Lone Tree, IA 52755	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-31	Bryce David Abbott	bryceabbott86@gmail.com	Lone Tree	Johnson	United States	Dixie Abbott	Andy Abbott	Signed	(1) The employer does not elect the employers’ liability coverage.	Bryce Abbott	bryceabbott86@gmail.com	Self	Lonetree	Johnson	IA	Dixie Abbott	Andy Abbott	Signed
2166	2024-04-20 13:38	Anonymous (not verified)	94.188.205.175	Cedar Valley Seamless, LLC	Limited Liability Company	1184 215th St, Jesup, IA 50648	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.	2024-04-20	Andrew Richard Trumbauer	cedarvalleyseamlessllc@gmail.com	Jesup	Buchanan	Iowa	James William Masteller	Andrew William Hamilton	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Richard Trumbauer	cedarvalleyseamlessllc@gmail.com	Owner/Operator	Jesup	Buchanan	Iowa	James William Masteller	Andrew William Hamilton	Signed
480	2021-04-14 15:58	Anonymous (not verified)	65.103.82.36	Home Cleaning Services	Proprietorship	1448 w 13th St Davenport IA 52804	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.	2020-01-01	Jolene Lyn Brown	j@gmail.com	davenport	scott	IA	Jamie Swanson	Andrew Swanson	Signed	(1) The employer does not elect the employers’ liability coverage.	Jolene Brown	j@gmail.com	owner	davenport	Scott	IA	Jamie Swanson	andrew Swanson	Signed
936	2022-02-25 10:47	Anonymous (not verified)	173.215.112.17	Arganbright Home Construction LLC	Limited Liability Company	2251 Soldier Trail, Panora, IA 50216	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-25	David E Arganbright	davearganbright@netins.net	Panora	Guthrie	IA	Cindy J Carstens	Andrew Randol	Signed	(1) The employer does not elect the employers’ liability coverage.	Christine M Arganbright	chrisbia@netins.net	Member	Panora	Guthrie	IA	Cindy J Carstens	Andrew Randol	Signed
2093	2024-03-13 15:53	Anonymous (not verified)	94.188.205.176	Tony Deutmeyer	Limited Liability Company	PO BOX 152 HIAWATHA IA 52233	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-13	Anthony John Deutmeyer	tonydeutmeyer@gmail.com	Hiawatha	Linn	Iowa	Lacey riley	Andrew prochaska	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony Deutmeyer	tonydeutmeyer@gmail.com	Self	Hiawatha	Linn	Iowa	Lacey riley	Andrew prochaska	Signed
688	2021-10-25 10:56	Anonymous (not verified)	75.91.173.195	Ami Westcott	Proprietorship	2672 F 52 Trail Parnell, IA 52325	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.	2021-10-25	Ami Lynn Westcott	ami.westcott@gmail.com	Parmell	Iowa	Iowa	Donald Scott Westcott	Andrew Patrick Brummel	Signed	(1) The employer does not elect the employers’ liability coverage.	Ami Lynn Westcott	ami.westcott@gmail.com	self	Parnell	Iowa	Iowa	Donald Scott Westcott	Andrew Patrick Brummel	Signed
1733	2023-07-10 14:30	Anonymous (not verified)	94.188.205.177	Leaf home	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.	2023-07-10	Andrew Koske	aokoz_23@outlook.com	East Moline	IL	United States	Andrew Koske	Andrew Koske	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Koske	aokoz_23@outlook.com	None	East Moline	IL	United States	Andrew Koske	Andrew Koske	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
229	2020-08-11 14:42	Anonymous (not verified)	75.162.158.159	Tanner Bruellman	Limited Liability Company	205 NE 25th ct grimes, 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.	2020-08-11	Tanner George Bruellman	bruellmantan_1@hotmail.com	Grimes	Poll	Iowa	Mary Kathleen Bruellman	Andrew Bruellman	Signed	(1) The employer does not elect the employers’ liability coverage.	Mary Kathleen Bruellman	bruellmantan_1@hotmail.com	Wife	Grimes	Polk	Iowa	Mary Kathleen Bruellman	Andrew James Bruellman	Signed
1098	2022-05-12 17:54	Anonymous (not verified)	199.66.15.123	Timothy W Robinson	Proprietorship	302 N Kenwood blvd Indianola IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-12	Timothy William Robinson	williamswork18@gmail.com	Indianola	Warren	Iowa	Sarah Anne Robinson	Andrew Gilbert Barber	Signed	(1) The employer does not elect the employers’ liability coverage.	Timothy William Robinson	williamswork18@gmail.com	Sole proprietor	Indianola	Warren	Iowa	Sarah Anne Robinson	Andrew Gilbert Barber	Signed
2063	2024-02-29 10:12	Anonymous (not verified)	94.188.205.177	Geral Lee Pattison	Proprietorship	22127 Hwy 52	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.	2024-02-29	Geral Lee Pattison	pattisonglee@gmail.com	GARNAVILLO	IA	IA	Lee Zapf	Andrew Corllet	Signed	(1) The employer does not elect the employers’ liability coverage.	Geral Lee Pattison	pattisonglee@gmail.com	Self	GARNAVILLO	IA	IA	Lee Zapf	Andrew Corllet	Signed
1969	2023-12-28 15:46	Anonymous (not verified)	94.188.205.176	Beau Vander Sluis	Proprietorship	3000 Seneca Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-28	Beau Vander Sluis	beauvsluis@gmail.com	Des Moines	Polk	United States	Braden Banning	Andrew Behanish	Signed	(1) The employer does not elect the employers’ liability coverage.	Beau Vander Sluis	beauvsluis@gmail.com	Same	Des Moines	Polk	United States	Braden Banning	Andrew Behanish	Signed
204	2020-07-15 11:21	Anonymous (not verified)	63.152.54.222	Tim Duggan	Limited Liability Company	1405 1st St. SW	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-07-15	Timothy M Duggan	tdc.inc30@gmail.com	Cedar Rapids	Iowa	United States	Joe Willis	Andrew Anson	Signed	(1) The employer does not elect the employers’ liability coverage.	Timothy M Duggan	tdc.inc30@gmail.com	President	Cedar Rapids	Iowa	United States	Joe Willis	Andrew Anson	Signed
1817	2023-08-24 12:29	Anonymous (not verified)	94.188.207.223	Global Roofing LLC	Limited Liability Company	504 Heritage Rd Cedar Falls IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-20	Jose Rafael Delgado Marin	grjrd808504@outlook.com	Cedar Falls	Black Hawk	Iowa	Noemi Guerrero	Andres B Montoya	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Rafael Delgado	grjrd808504@outlook.com	member	Cedar Falls	Black Hawk	Iowa	Noemi Guerrero	Andres B Montoya	Signed
1818	2023-08-25 15:16	Anonymous (not verified)	94.188.207.224	Global Roofing LLC	Limited Liability Company	504 Heritage Rd Cedar Falls IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-08-20	Yenifer Yomara Hernandez Solis	Grjrd808504@outlook.com	Cedar Falls	Black Hawk	Iowa	Noemi Guerrero	Andres B Montoya	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Rafael Delgado Marin	Grjrd808504@outlook.com	member	Cedar Falls	Black Hawk	Iowa	Noemi Guerrero	Andres B Montoya	Signed
931	2022-02-21 15:04	Anonymous (not verified)	69.18.14.11	Lawn's Plus	Proprietorship	6082 Northwest Beaver Drive, Johnston, Iowa 50131, United States	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-01	Javier Nieto	jacobanderson55@yahoo.com	Des Moines	Polk	Iowa	Jacob Anderson	Andrea Nieto	Signed	(1) The employer does not elect the employers’ liability coverage.	Javier Nieto	jacobanderson55@yahoo.com	Self	Des Moiens	Polk	Iowa	Jacob Anderson	Andrea Nieto	Signed
614	2021-08-20 12:20	Anonymous (not verified)	172.58.235.242	Darren Qualls	Proprietorship	1515 Dewitt St. Ellsworth. IA 50075	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-20	Darren Wade Qualls	d.qualls@outlook.com	Ellsworth	Hamilton	IA	Jeannie Kathleen Qualls	Andrea Littleton	Signed	(1) The employer does not elect the employers’ liability coverage.	Darren Wade Qualls	d.qualls@outlook.com	Self/Proprietor	Ellsworth	IA	IA	Jeannie Kathleen Qualls	Andrea Littleton	Signed
1744	2023-07-13 13:52	Anonymous (not verified)	94.188.205.176	T-Rex Construction LLC	Limited Liability Company	1203 Bluegrass Circle Unit 4 Cedar Falls Iowa 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-12	Claudia Rodriguez De Nunez	t.rexbigbiz@gmail.com	CEDAR FALLS	IA	United States	Ana Chavez	Alicia Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Guillermo Nunez	claudia.rodriguez.213@gmail.com	Spouse	CEDAR FALLS	IA	United States	Alicia Garcia	Ana Chavez	Signed
1596	2023-04-24 15:48	Anonymous (not verified)	94.188.205.174	Loyal Transport INC	Proprietorship	1987 Middle Calmar Road, Decorah, IA 52101	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.	2022-02-01	Lloyd Bjergum	aryan1950@hotmail.com	Decorah, IA	Winneshiek	Iowa	Allen Monroe	Amy Ryan	Signed	(1) The employer does not elect the employers’ liability coverage.	Lloyd Bjergum	aryan1950@hotmail.com	Self	Decorah,	Winneshiek	Iowa	Allen Monroe	Amy Ryan	Signed
1016	2022-03-29 14:26	Anonymous (not verified)	104.145.202.155	S.M.Trucking	Proprietorship	3270 Hwy 69	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-29	Steve Miller	S.M.Trucking52@gmail.com	3270 Hwy 69 Forest City	Hancock	Ia	Julie Miller	Amy Picha	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Miller	S.M.Trucking52@gmail.com	Owner	3270 Hwy 69 Forest City	Hancock	Ia	Julie Miller	Amy Picha	Signed
1249	2022-08-09 14:14	Anonymous (not verified)	166.181.82.131	Kelly Kellogg	Proprietorship	1305 N 1st st apt 16	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-09	Kelly Kellogg	Kkell0223@gmail.com	Indianola	Warren	Iowa	Kelly Kellogg	Amy Kellogg	Signed	(1) The employer does not elect the employers’ liability coverage.	Kelly's Flooring	Kkell0223@gmail.com	Myself	1305 N 1st st apt 16	Warren	Iowa	Kelly Kellogg	Amy Kellogg	Signed
2078	2024-03-06 16:19	Anonymous (not verified)	94.188.207.228	Iowa's Gutter Specialist LLC	Limited Liability Company	221 4th St SE Hampton Iowa 50441	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-06	Dustin Halverson	dh42312695@gmail.com	Hampton	Iowa	United States	Levi Paine	Amy Hayes	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin Halverson	dh42312695@gmail.com	Owner	Hampton	Iowa	United States	Levi Paine	Amy Hayes	Signed
178	2020-06-08 13:51	Anonymous (not verified)	173.21.16.200	Daniel Mullanack	Limited Liability Company	1208 Franklin St. Buffalo, IA 52728	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2020-06-08	daniel mullanack	mullanackbuilders@mediacombb.net	buffalo	scott	iowa	brandon brooks	amy carlson	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	linda mullanack	mullanackbuilders@mediacombb.net	office manager	buffalo	scott	iowa	brandon brooks	amy carlson	Signed
880	2022-02-01 14:05	Anonymous (not verified)	207.45.88.5	Known Labs LLC	Limited Liability Partnership	8350 Ep True Pkwy, UNIT 1201	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.	2022-02-01	Marcus Antonio Smith	mark@knownlabs.net	West Des Moines	Dallas	IA	Dan Morgan III	Amber Smith	Signed	(1) The employer does not elect the employers’ liability coverage.	Marcus Antonio Smith	mark@knownlabs.net	Owner	West Des Moines	IA	IA	Daniel Morgan III	Amber Smith	Signed
339	2020-12-15 15:23	Anonymous (not verified)	74.221.46.229	CORRECTIONVILLE GOLF CLUB INC	Limited Liability Company	1300 HACKBERRY STREET CORRECTIONVILLE IA 51016	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.	2020-12-15	KATIE EDWARDS	KEDWARDS@FNBCORRECTIONVILLE.COM	CORRECTIONVILLE	WOODBURY	IA	CANDACE JACOBSON	AMBER HANSEN	Signed	(1) The employer does not elect the employers’ liability coverage.	KIM MEBIUS	KMEBIUS@FNBCORRECTIONVILLE.COM	PRESIDENT	CORRECTIONVILLE	WOODBURY	IA	CANDACE JACOBSON	AMBER HANSEN	Signed
1059	2022-04-19 15:06	Anonymous (not verified)	64.186.23.83	CORRECTIONVILL GOLF CLUB, INC	Limited Liability Company	1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-19	NICK HEATH	dogboy3485@yahoo.com	CORRECTIONVILLE	WOODBURY	IOWA	CANDACE JACOBSON	AMBER HANSEN	Signed	(1) The employer does not elect the employers’ liability coverage.	KATIE EDWARDS	kedwards@fnbcorrectionville.com	SEC/TREASURER	CORRECTIONVILLE	WOODBURY	IOWA	CANDACE JACOBSON	AMBER HANSEN	Signed
1060	2022-04-19 15:08	Anonymous (not verified)	64.186.23.83	CORRECTIONVILLE GOLF CLUB, INC	Limited Liability Company	1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-19	ADAM KELLY	dslkraz@gmail.com	CORRECTIONVILLE	WOOD	IWOA	CANDACE	AMBER HANSEN	Signed	(1) The employer does not elect the employers’ liability coverage.	KATIE EDWARDS	kedwards@fnbcorrectionville.com	SEC/TREASURER	CORRECTIONVILLE	WOODBURY	IOWA	CANDACE JACOBSON	AMBER HANSEN	Signed
652	2021-09-22 21:52	Anonymous (not verified)	209.152.66.250	Robert Stutzman	Limited Liability Company	33784 Hwy 22 Keota, IA 25548	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.	2021-09-22	Robert L Stutzman	bnbstutzman@gmail.com	Keota	Keokuk	Iowa	Jo Edgington	Amber Gent	Signed	(1) The employer does not elect the employers’ liability coverage.	Sandra K Stutzman	iafarmgirl90@gmail.com	Daughter	Keota	Keokuk	Iowa	Jo Edgington	Amber Gent	Signed
19	2019-12-31 16:29	Anonymous (not verified)	172.58.83.45	A.M. Tile	Proprietorship	3824 122nd 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.	2019-12-31	Amar Music	amarmusic01@gmail.com	Urbandale	IA	United States	Sefik Music	Amara Crncevic	Signed	(1) The employer does not elect the employers’ liability coverage.	Amar Music	amarmusic01@gmail.com	Owner	Urbandale	IA	United States	Sefik Music	Amara Crncevic	Signed
20	2019-12-31 16:36	Anonymous (not verified)	172.58.83.45	A.M. Tile	Proprietorship	3824 122nd 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.	2019-12-31	Amar Music	amarmusic01@gmail.com	Urbandale	IA	United States	Sefik Music	Amara Crncevic	Signed	(1) The employer does not elect the employers’ liability coverage.	Omer Okic	ultimate.exteriors@gmail.com	Owner	Des Moines	Polk	IA	Sefik Music	Amara Crncevic	Signed
427	2021-03-10 11:52	Anonymous (not verified)	66.188.136.150	Ronald Tessen	Proprietorship	493 Hill St. Green Lake, WI 54941	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-10	Ronald Tessen	kschumacher@tricorinsurance.com	Green Lake	Green Lake	WI	Russell Masartis	Amanda Seeberger	Signed	(1) The employer does not elect the employers’ liability coverage.	Ronald Tessen	kschumacher@tricorinsurance.com	Same	Green Lake	Green Lake	WI	Russell Masartis	Amanda Seeberger	Signed
428	2021-03-10 12:38	Anonymous (not verified)	66.188.136.150	John Smith	Proprietorship	2490 E Main St. Lot 41, Plainfield, IN 46168	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-03-10	John Smith	kschumacher@tricorinsurance.com	Plainfield	Hendricks	IN	Russell Masartis	Amanda Seeberger	Signed	(1) The employer does not elect the employers’ liability coverage.	John Smith	kschumacher@tricorinsurance.com	Same	Plainfield	Hendricks	IN	Russell Masartis	Amanda Seeberger	Signed
458	2021-04-05 11:59	Anonymous (not verified)	66.188.136.150	Joseph Chance	Proprietorship	815 Richards Dr. Shorewood, IL 60404	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.	2021-03-29	Joseph Chance	kschumacher@tricorinsurance.com	Shorewood	Will	IL	Russell Masartis	Amanda Seeberger	Signed	(1) The employer does not elect the employers’ liability coverage.	Joseph Chance	kschumacher@tricorinsurance.com	Same	Shorewood	Will	IL	Russell Masartis	Amanda Seeberger	Signed
1119	2022-05-18 11:51	Anonymous (not verified)	104.201.75.222	Gentry Hardware inc.	Partnership	308 5th 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.	2022-05-18	Nathan Dwaine Gentry	gentrynathan@hotmail.com	Rockwellcity	Calhoun	Iowa	Emily Bethann Gentry	Amanda Margaret Albee	Signed	(1) The employer does not elect the employers’ liability coverage.	Nathan Dwaine Gentry	gentrynathan@hotmail.com	Owner	Rockwellcity	Calhoun	Iowa	Emily Bethann Gentry	Amanda Margaret Albee	Signed
491	2021-04-20 15:57	Anonymous (not verified)	199.102.210.217	mjm,inc	Proprietorship	32345 200th st dallas centert 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.	2021-04-20	john paul wewrner	johnpwerner17@gmail.com	osage	michell	ia	carolyn lee werner	amanda lee johnson	Signed	(1) The employer does not elect the employers’ liability coverage.	johnwerner	johnpwerner17@gmail.com	friend	osage	mithell	ia	carolyn lee werner	amanda lee johnson	Signed
123	2020-04-16 08:33	Anonymous (not verified)	159.242.36.129	Paul Brown	Proprietorship	5 Cedar Ridge CT, Ventura, IA 50482-8992	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.	2020-04-16	Paul Brown	cedars4@cltel.net	Ventura	Cerro Gordo	IA	Tom Stephany	Amanda Korenberg	Signed	(1) The employer does not elect the employers’ liability coverage.	Paul Brown	cedars4@cltel.net	self	Ventura	Cerro Gordo	IA	Tom Stephany	Amanda Korenberg	Signed
1923	2023-11-27 11:21	Anonymous (not verified)	94.188.207.230	Chilled LLC	Limited Liability Company	236 Meadow Breeze Ln Center Point IA 52213	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.	2023-11-27	Lindsy J Trotter	Lindsy@chilledfreezermeals.com	Center Point	Linn	Iowa	Abbie Snakenberg	Amanda Guttau	Signed	(1) The employer does not elect the employers’ liability coverage.	Lindsy Trotter	Lindsy@chilledfreezermeals.com	Owner	Center Point	Linn	Iowa	Abbie Snakenberg	Amanda Guttau	Signed
1375	2022-11-18 10:21	Anonymous (not verified)	166.181.87.119	Heff Built Construction LLC	Limited Liability Company	1403 Kodiak Dr NW Cedar Rapids, IA 52405	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.	2022-11-18	Jacob Heffernen	jheffernen@gmail.com	Cedar Rapids	Linn	IA	Kyle Reid	Amanda Frese	Signed	(1) The employer does not elect the employers’ liability coverage.	Jacob Heffernen	jheffernen@gmail.com	N/A	Cedar Rapids	Linn	IA	Kyle Reid	Amanda Frese	Signed
1376	2022-11-18 10:22	Anonymous (not verified)	166.181.87.119	Ashley Heffernen	Proprietorship	4009 Majestic Ct NE Cedar Rapids Iowa 52411	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.	2022-11-18	Ashley Rae Heffernen	ashley.heffernen@gmail.com	Cedar Rapids	Linn	Iowa	Kyle Reid	Amanda Frese	Signed	(1) The employer does not elect the employers’ liability coverage.	Ashley Rae Heffernen	ashley.heffernen@gmail.com	Self	Cedar Rapids	Linn	Iowa	Kyle Reid	Amanda Frese	Signed