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:
1875	2023-10-23 11:34	Anonymous (not verified)	94.188.205.176	Makers Blinds LLC	Limited Liability Company	3220 44Th St Des Moines, IA 50310	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-23	Ryan Seiler	makersblinds@gmail.com	Des Moines	Polk	Iowa	Jon Buller	Terry Miles	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Seiler	makersblinds@gmail.com	Manager	Des Moines	Polk	Iowa	Jon Buller	Terry Miles	Signed
57	2020-02-10 15:33	Anonymous (not verified)	198.167.182.164	AllEnhancements LLC	Limited Liability Company	1122 Woodland Ln, LeClaire, IA 52753	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.	2020-01-31	Brett Allen	allenhancementsllc@outlook.com	LeClaire	Scott	Iowa	Steven J Fishman	E Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Brett Allen	allenhancementsllc@outlook.com	Managing Member	LeClaire	Scott	Iowa	Steven J Fishman	E Dyan Kriener	Signed
59	2020-02-11 11:34	Anonymous (not verified)	198.167.182.164	Besch Electric LLC	Limited Liability Company	317 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.	2020-02-03	Daniel Besch	beschd@hotmail.com	Riverside	Washington	Iowa	Steven J Fishman	E Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Besch	beschd@hotmail.com	Managing Member	Riverside	Washington	Iowa	Steven J Fishman	E Dyan Kriener	Signed
64	2020-02-18 10:02	Anonymous (not verified)	198.167.182.164	Elite Electrical Service LLC	Limited Liability Company	2035 Lynncrest Dr, Coralville, IA 52241	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-18	Sean Brogan	brogan_sean@hotmail.com	Coralville	Johnson	Iowa	Kyle Stahle	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Sean Brogan	brogan_sean@hotmail.com	Managing Member	Coralville	Johnson	Iowa	Kyle Stahle	Dyan Kriener	Signed
67	2020-02-19 10:16	Anonymous (not verified)	198.167.182.164	AWF579 LLC	Limited Liability Company	13 Lynden Dr NE, Iowa City, IA 52240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-02-18	Jeffrey Schiltz	jeffschiltz2@yahoo.com	Iowa City	Johnson	Iowa	Kyle Stahle	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Jeffrey Schiltz	jeffschiltz2@yahoo.com	Managing Member	Iowa City	Johnson	Iowa	Kyle Stahle	Dyan Kriener	Signed
84	2020-02-28 15:30	Anonymous (not verified)	198.167.182.164	Rid-A-Bird Inc.	Limited Liability Company	3116 Friendship St. Iowa City IA 52245	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.	2020-02-28	Keith Wilson	kwilson@windowgenie.com	Iowa City	Johnson	Iowa	Dyan Kriener	Marcia A Colvin	Signed	(1) The employer does not elect the employers’ liability coverage.	Keith Wilson	kwilson@windowgenie.com	Managing member	Iowa City	Johnson	Iowa	Dyan Kriener	Marcia A Colvin	Signed
85	2020-03-09 08:17	Anonymous (not verified)	198.167.182.164	Simply Anchored LLC dba Simply Mae's	Limited Liability Company	601 Broad St, Story City, IA 50248	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.	2020-03-05	Jessi Kettenacker	jessi@simplymaes.com	Story City	Story	Iowa	Lynn McKinney	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Jessi Kettenacker	jessi@simplymaes.com	Managing Member	Story City	Story	Iowa	Lynn McKinney	Dyan Kriener	Signed
86	2020-03-09 08:19	Anonymous (not verified)	198.167.182.164	Simply Anchored LLC dba Simply Mae's	Limited Liability Company	601 Broad St, Story City, IA 50248	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.	2020-03-05	Cande Coulter	cande@simplymaes.com	Story City	Story	Iowa	Lynn McKinney	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Candy Coulter	cande@simplymaes.com	Managing Member	Story City	Story	Iowa	Lynn McKinney	Dyan Kriener	Signed
151	2020-05-07 15:57	Anonymous (not verified)	198.167.182.164	Hawk-I Trucking LLC	Limited Liability Company	521 Greenfield Dr, Tiffin, IA 52340	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-05-06	Chad Lee Freeman	ricenogle@southslope.net	Tiffin	Johnson	IA	Scott Freeman	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Chad Lee Freeman	ricenogle@southslope.net	Managing Member	Tiffin	Johnson	IA	Scott Freeman	Dyan Kriener	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
489	2021-04-20 13:47	Anonymous (not verified)	69.63.16.2	Mow-n-Mor Lawn & Landscaping LLC	Limited Liability Company	2585 500th St SW, Kalona, IA 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.	2021-04-19	Robert Sieren	mtesdell@yahoo.com	Kalona	Johnson	Iowa	Scott Freeman	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Robert Sieren	mtesdell@yahoo.com	Managing Member	Kalona	Johnson	Iowa	Scott Freeman	Dyan Kriener	Signed
505	2021-05-10 07:06	Anonymous (not verified)	69.63.16.2	Three Boys Contracting LLC	Limited Liability Company	1108 Cullen Dr, Tiffin, IA 52340	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-08	Brandon J Campbell	threeboyscarpentry@gmail.com	Tiffin	Johnson	Iowa	Steve Fishman	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandon J Campbell	threeboyscarpentry@gmail.com	Managing Member	Tiffin	Johnson	Iowa	Steve Fishman	Dyan Kriener	Signed
1264	2022-08-16 21:22	Anonymous (not verified)	50.82.84.19	Nogotta Trucking LLC	Limited Liability Company	16617 Wilden Dr, Clive IA 50325	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-08-16	Adam Dickinson	nogottatruckingllc@gmail.com	Clive	IA	United States	Gary Dickinson	Mike Martens	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Dickinson	nogottatruckingllc@gmail.com	Managing Member	Clive	IA	United States	Gary Dickinson	Mike Martens	Signed
1291	2022-09-02 13:24	Anonymous (not verified)	173.20.146.6	Nicci Keck LLC	Limited Liability Company	1107 Pheasant Valley St, Iowa City, IA 52246	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.	2020-09-02	Nicole Keck	niccikeckllc@gmail.com	Iowa City	Iowa	United States	Evangeline Kadera	Denise Kandel	Signed	(1) The employer does not elect the employers’ liability coverage.	Nicole Keck	niccikeckllc@gmail.com	Managing Member/Owner/President	Iowa City	Johnson	Iowa	Evangeline Kadera	Denise Kandel	Signed
1292	2022-09-02 13:26	Anonymous (not verified)	173.20.146.6	Nicci Keck LLC	Limited Liability Company	1107 Pheasant Valley St, Iowa City, IA 52246	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.	2020-09-02	Benjamin Darbro	darbrob@gmail.com	Iowa City	Iowa	United States	Evangeline Kadera	Denise Kandel	Signed	(1) The employer does not elect the employers’ liability coverage.	Nicole Keck	niccikeckllc@gmail.com	Managing Member/Owner/President	Iowa City	Johnson	Iowa	Evangeline Kadera	Denise Kandel	Signed
171	2020-06-01 16:17	Anonymous (not verified)	99.203.98.130	Jose Jurado	Limited Liability Company	3825 NE 43rd ct 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.	2020-06-01	Jose Jurado	trustedroofingllc@gmail.com	Des Moines	Polk	IOWA	Sterling Bean	Sigifredo Corral	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Jurado	trustedroofingllc@gmail.com	Marcos Jurado	Des Moines	Polk	IOWA	Sterling Bean	Sigifredo Corral	Signed
125	2020-04-20 19:01	Anonymous (not verified)	67.22.196.182	Driven School of Driving	Limited Liability Company	451 E 1st 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.	2020-04-20	Justin J. Franken	drivenschoolofdriving@gmail.com	Sioux Center	Sioux	IA	Robyn Franken	Gracyn Franken	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Franken	drivenschoolofdriving@gmail.com	Me	Sioux Center	Sioux	IA	Robyn Franken	Gracyn Franken	Signed
259	2020-09-16 15:44	Anonymous (not verified)	174.243.82.6	Freedom Maintenance Services LLC	Limited Liability Company	1633 2nd St Boone, IA 50036	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.	2020-09-16	Cole Keith McDonald	cole.freedomservices@outlook.com	Boone	Boone	IA	Troy Thomas Graen	Kurtis Joseph Wendl	Signed	(1) The employer does not elect the employers’ liability coverage.	Cole Keith McDonald	cole.freedomservices@outlook.com	Me	Boone	Boone	IA	Troy Thomas Graen	Kurtis Joseph Wendl	Signed
595	2021-08-03 13:53	Anonymous (not verified)	174.248.224.252	Joseph r cunningham dba freedom field services	Proprietorship	6285 n 67th ave w Baxter iowa 50028	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	Joseph r Cunningham jr.	joecunningham1966@protonmail.com	Baxter	Jasper	Iowa	Chelsey Cunningham	Chris Cort	Signed	(1) The employer does not elect the employers’ liability coverage.	Joseph r cunningham jr	joecunningham1966@protonmail.com	Me	Baxter	Jasper	Iowa	Chelsey cunningham	Chris cort	Signed
1424	2023-01-17 17:34	Anonymous (not verified)	173.191.246.189	Jabe Ramsey	Proprietorship	216 South Park Street Osceola, IA 50213	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.	2023-01-17	Jabe Hatfield Ramsey	jaberamsey@icloud.com	Osceola	IA	United States	Sofia Contreras	Katie Anne Carson	Signed	(1) The employer does not elect the employers’ liability coverage.	Jabe Ramsey	jaberamsey@icloud.com	ME	Osceola	Clarke	IOWA	Sofia Contreras	Katie Anne Carson	Signed
1889	2023-11-01 06:44	Anonymous (not verified)	94.188.207.226	Williams Hardwood Flooring LLC	Limited Liability Company	P.O. Box 22 Marion, 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.	2023-11-01	Chad Everett William	williamshardwoodflooringllc@gmail.com	Anamosa	Jones	IA	Tara Williams	Sarah Williams	Signed	(1) The employer does not elect the employers’ liability coverage.	Chad E Williams	williamsharfwoodflooringllc@gmail.com	Me	Anamosa	Jones	IA	Tara Williams	Sarah Williams	Signed
1915	2023-11-21 04:06	Anonymous (not verified)	94.188.207.225	Advanced Foam Systems	Limited Liability Company	1378 Midway Ave Tripoli IA 50676	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-11-18	Randy Block	advancedfoamsystems@yahoo.com	Tripoli	Bremer	Iowa	Linda Block	Brady Block	Signed	(1) The employer does not elect the employers’ liability coverage.	Randy Block	advancedfoamsystems@yahoo.com	Me	Tripoli	Bremer	Iowa	Linda block	Brady block	Signed
2061	2024-02-28 14:16	Anonymous (not verified)	94.188.205.166	Cael Gulrud	Proprietorship	206 W Main St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-28	Cael Gulrud	gulrud8728@gmail.com	Calmar	IA	United States	Belle Olsgard	David Gulrud	Signed	(1) The employer does not elect the employers’ liability coverage.	Cael Gulrud	gulrud8728@gmail.com	Me	Calmar	IA	United States	Belle Olsgard	David Gulrud	Signed
24	2020-01-03 12:41	Anonymous (not verified)	63.152.13.239	Eden Plumbing LLC TJ Eden	Limited Liability Company	502 Packwaukee Street New Hartford, IA 50660	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.	2020-01-03	TJ Eden	edentj@aol.com	New Hartford	IA	United States	Ann Robinson	Nate Schmidt	Signed	(1) The employer does not elect the employers’ liability coverage.	PDCM Insurance- Nate Schmidt	NSCHMIDT@PDCM.COM	Member	New Hartford	Butler	Iowa	Ann Robinson	Nate Schmidt	Signed
108	2020-04-01 16:50	Anonymous (not verified)	206.72.23.71	Heartland Renovations, LLC	Limited Liability Company	50253 290th Street, Kelley, IA 50134	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.	2020-04-01	Troy Van Maaren	almostanything2@gmail.com	Kelley	Iowa	United States	Tammy J Reid	Todd L Greenslit	Signed	(1) The employer does not elect the employers’ liability coverage.	Troy Van Maaren	almostanything2@gmail.com	Member	Kelley	Story	Iowa	Tammy J Reid	Todd L Greenslit	Signed
152	2020-05-11 15:56	Anonymous (not verified)	198.167.182.164	Hawk-I Trucking LLC	Limited Liability Company	521 Greenfield Dr, Tiffin, IA 52340	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.	2020-05-11	Tyler Rogers	tylerrogersinc@yahoo.com	Iowa City	Johnson	Iowa	Scott Freeman	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Tyler Rogers	tylerrogersinc@yahoo.com	Member	Iowa City	Johnson	Iowa	Scott Freeman	Dyan Kriener	Signed
504	2021-05-06 15:43	Anonymous (not verified)	75.162.84.34	Erreguin Labra Roofing LLC	Limited Liability Company	642 S Washington Ave Mason City IA 50401	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-06	Hilario Labra Trejo	erreguin06@gmail.com	mason city	cerro gordo	Iowa	Liliana Sanchez	Yolanda Mendoza	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Fernando Erreguin	Erreguin06@gmail.com	member	Mason city	cerro gordo	iowa	Liliana sanchez	yolanda mendoza	Signed
512	2021-05-11 13:12	Anonymous (not verified)	173.31.147.225	RUTHVEN ROCKS LLC	Limited Liability Company	1205 ROLLING ST RUTHVEN IOWA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-11	JEFF CACEK	JEFF@RUTHVENROCKS.COM	RUTHVEN	PALO ALTO	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	JEFF CACEK	joel@walkerinsuranceia.com	MEMBER	RUTHVEN	PALO ALTO	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
513	2021-05-11 13:14	Anonymous (not verified)	173.31.147.225	RUTHVEN ROCKS LLC	Limited Liability Company	1205 ROLLING ST RUTHVEN IOWA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-11	KEITH CACEK	KEITH@RUTHVENROCKS.COM	RUTHVEN	PALO ALTO	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	KEITH CACEK	joel@walkerinsuranceia.com	MEMBER	RUTHVEN	PALO ALTO	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
514	2021-05-11 13:16	Anonymous (not verified)	173.31.147.225	RUTHVEN ROCKS LLC	Limited Liability Company	1205 ROLLING ST RUTHVEN IOWA 51358	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-11	MATT CACEK	MATT@RUTHVENROCKS.COM	MILFORD	DICKINSON	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	MATT CACEK	joel@walkerinsuranceia.com	MEMBER	MILFORD	PALO ALTO	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
544	2021-06-21 16:10	Anonymous (not verified)	97.125.169.60	Tenant Improvement Services, LLC	Limited Liability Company	3011 Justin Drive, Urbandale, IA 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-06-21	Jake Etter	jake@tenantimprovemetnsiowa.com	Polk City	Polk	Iowa	Ashley Overton	Aylah Etter	Signed	(1) The employer does not elect the employers’ liability coverage.	Jake Etter	jake@tenantimprovementsiowa.com	Member	Polk City	Polk	Iowa	Ashley Overton	Aylah Etter	Signed
547	2021-06-24 08:05	Anonymous (not verified)	97.125.169.60	Tenant Improvement Services, LLC	Limited Liability Company	3011 Justin Drive, Urbandale, IA 50322	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-06-24	Josh Chiles	josh@tenantimprovementsiowa.com	Des Moines	Polk	Iowa	John Martin	Johnny Holman	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Chiles	josh@tenantimprovementsiowa.com	Member	Des Moines	Polk	Iowa	John Martin	Johnny Holman	Signed
672	2021-10-13 16:05	Anonymous (not verified)	75.162.218.218	Arturos Interiors LLC	Limited Liability Company	3305 se 22nd apt 15 Des Moines IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-09-29	Arturo mejia	arturomcruz20@hotmail.com	Des Moines	polk	IA	yolanda mendoza	liliana sanchez	Signed	(1) The employer does not elect the employers’ liability coverage.	Arturo Mejia	arturomcruz20@hotmail.com	member	Des Moines	polk	IA	Yolanda Mendoza	lialiana sanchez	Signed
702	2021-11-01 09:23	Anonymous (not verified)	173.28.195.56	Garcia Snow Removal	Limited Liability Company	213 E 7th Street, West Liberty, Iowa 52776	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-11-01	Benji A Garcia	garciabenji23@gmail.com	West Liberty	IA	Norway	Luis Ordenana-Choez	Vicente Garcia	Signed	(1) The employer does not elect the employers’ liability coverage.	Benji Garcia	garciabenji23@gmail.com	Member	West Liberty	Muscatine	Iowa	Luis Ordenana-Choez	Vicente Garcia	Signed
814	2021-12-27 13:07	Anonymous (not verified)	216.51.155.17	I & B Ag Supply, LLC	Limited Liability Company	3807 20th Ave Fenton, IA 50539	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.	2021-12-27	Israel Winter	israel.winter@hotmail.com	Fenton	Kossuth	Iowa	Jonathan Gesink	Benjamin Wiersma	Signed	(1) The employer does not elect the employers’ liability coverage.	Israel Winter	israel.winter@hotmail.com	Member	Fenton	Kossuth	Iowa	Jonathan Gesink	Benjamin Wiersma	Signed
860	2022-01-27 11:31	Anonymous (not verified)	69.63.16.2	Dreams 2 Reality Construction LLC	Limited Liability Company	17615 Meredith Dr, Waukee, IA 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-26	Rob Rubsam	rob@dreams2reality.us	Waukee	Dallas	Iowa	Kyle Stahle	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Rob Rubsam	rob@dreams2reality.us	Member	Waukee	Dallas	Iowa	Kyle Stahle	Dyan Kriener	Signed
861	2022-01-27 11:33	Anonymous (not verified)	69.63.16.2	Dreams 2 Reality Construction LLC	Limited Liability Company	17615 Meredith Dr, Waukee, IA 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-26	Lisa Rubsam	lisa@dreams2reality.us	Waukee	Dallas	Iowa	Kyle Stahle	Dyan Kriener	Signed	(1) The employer does not elect the employers’ liability coverage.	Lisa Rubsam	lisa@dreams2reality.us	Member	Waukee	Dallas	Iowa	Kyle Stahle	Dyan Kriener	Signed
919	2022-02-16 21:13	Anonymous (not verified)	208.126.203.31	K & D Land Improvement, LLC	Limited Liability Company	2719 270th Street, Lehigh, Iowa 50557	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-16	Daniel Hansen	dhansen@lvcta.com	Lehigh	Webster	Iowa	Karen Hansen	Cathy Mickelson	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Hansen	dhansen@lvcta.com	Member	Lehigh	Webster	Iowa	Karen Hansen	Cathy Mickelson	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
1489	2023-02-28 16:06	Anonymous (not verified)	94.188.207.228	Nate's Tractor LLC	Limited Liability Company	11939 birch Ave Riceville, IA 50466	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-28	Nathan Fox	nate@natestractor.com	Riceville	Howard	Iowa	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Nathan Fox	nate@natestractor.com	Member	Riceville	Howard	Iowa	Chris Fye	Darrel Elsbernd	Signed
1502	2023-03-07 12:40	Anonymous (not verified)	94.188.205.177	Joseph Martin	Limited Liability Company	P O Box 277 Lime Springs, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-18	Joseph Martin	darrele@ciains.biz	Lime Springs	Howard	Iowa	Darrel Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Al's Roofing LLC	darrele@ciains.biz	Member	Lime Springs	Howard	Iowa	Darrel Elsbernd	Chrus Fye	Signed
1504	2023-03-07 18:38	Anonymous (not verified)	94.188.207.227	Mathias Heating & Cooling	Limited Liability Company	1449 19th Pl West Des Moines, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-03-07	Justin Mathias	emathiasj@gmail.com	West Des Moines	Polk	Iowa	Jesse Parker	Jeff Boucher	Signed	(1) The employer does not elect the employers’ liability coverage.	Justin Mathias	emathiasj@gmail.com	Member	West Des Moines	Polk	Iowa	Jesse Parker	Jeff Boucher	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
1789	2023-08-08 13:18	Anonymous (not verified)	94.188.207.230	Corridor Construction Co., LLC	Limited Liability Company	P.O. Box 8540 Cedar Rapids, IA 52408	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.	2023-08-08	Steven H. Miller	jimfortmann60@gmail.com	Cedar Rapids	Linn	IA	James J. Fortmann	Ruth Ann Beers	Signed	(1) The employer does not elect the employers’ liability coverage.	Steven H. Miller	jimfortmann60@gmail.com	Member	Cedar Rapids	Linn	IA	James J. Fortmann	Ruth Ann Beers	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
1948	2023-12-11 10:36	Anonymous (not verified)	94.188.207.224	Just Like New Details LLC	Limited Liability Company	4665 NE 7th St. 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.	2023-12-11	Trinity Schroeder	trinity@justlikenewdetails.com	Des Moines	Polk	Iowa	Jayson Jones	Nikki Wilks	Signed	(1) The employer does not elect the employers’ liability coverage.	Trinity Schroeder	trinity@justlikenewdetails.com	Member	Des Moines	Polk	Iowa	Jayson Jones	Nikki Wilks	Signed
1699	2023-06-22 07:36	Anonymous (not verified)	94.188.205.175	V2E Advisors LLC	Limited Liability Company	701 Lakeview Ct, Tiffin, IA 52340	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-22	Tyler Rhamy	trhamy@v2eadvisors.com	Tiffin	Iowa	United States	Tasha Rhamy	Tom Rhamy	Signed	(1) The employer does not elect the employers’ liability coverage.	Tyler Rhamy	trhamy@v2eadvisors.com	Member / President	Tiffin	Johnson	Iowa	Tom Rhamy	Tasha Rhamy	Signed
90	2020-03-13 15:44	Anonymous (not verified)	173.24.190.134	Heath Householder	Limited Liability Company	2 N Huron Street, Emmetsburg IA 50536	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-07	Heath Householder	heath679@live.com	Emmetsburg	Palo Alto	Iowa	Scott Wirtz	Candie Clark	Signed	(1) The employer does not elect the employers’ liability coverage.	Heath Householder	heath679@live.com	Member of LLC	Emmetsburg	Palo Alto	Iowa	Scott Wirtz	Candie Clark	Signed
91	2020-03-13 15:51	Anonymous (not verified)	173.24.190.134	Small Town RV, LLC	Limited Liability Company	112 Miller 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.	2020-03-09	Heath Sabin	sales@smalltownrv.com	Mallard	Palo Alto	Iowa	Dave Walters	Candie Clark	Signed	(1) The employer does not elect the employers’ liability coverage.	Heath Sabin	sales@smalltownrv.com	Member of LLC	Mallard	Palo Alto	Iowa	Dave Walters	Candie Clark	Signed

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