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:
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
530	2021-05-25 08:30	Anonymous (not verified)	159.242.43.24	FoxTrot Foods, LLC	Limited Liability Company	13-15 S Federal 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.	2021-05-25	Melissa Fabian	melissafabian@yahoo.com	Mason City	Cerro Gordo	Iowa	Jenny McIntyre	Dan Wunschel	Signed	(1) The employer does not elect the employers’ liability coverage.	Melissa Fabian	melissafabian@yahoo.com	Owner-Member	Mason City	Cerro Gordo	Iowa	Jenny McIntyre	Dan Wunschel	Signed
531	2021-05-26 13:02	Anonymous (not verified)	75.162.156.185	Xander Wessels	Limited Liability Company	719 10TH ST NE	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.	2021-05-26	Alexander Wessels	kprepair@outlook.com	MASON CITY	IA	IA	Dusty Howe	Sadie Lonning	Signed	(1) The employer does not elect the employers’ liability coverage.	Dusty Howe	dusty.mcelectric@gmail.com	Sub Contractor	Mason City	Cerro Gordo	Iowa	Dusty Howe	Sadie Lonning	Signed
533	2021-06-03 20:37	Anonymous (not verified)	75.162.171.128	KP Repair LLC	Limited Liability Company	719 10th St. NE Mason City, 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.	2021-06-03	Alexander Wessels	kprepair@outlook.com	MASON CITY	Cerro Gordo	IA	Sadie Lonning	Dusty Howe	Signed	(1) The employer does not elect the employers’ liability coverage.	Alexander Wessels	kprepair@outlook.com	Owner	MASON CITY	Cerro Gordo	IA	Sadie Lonning	Dusty Howe	Signed
779	2021-12-06 10:43	Anonymous (not verified)	172.83.21.144	Munn Enterprises LLC	Limited Liability Company	118 14th Avenue South	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.	2021-12-06	Douglas A Munn	munnent1328@gmail.com	Clear lake	IA	IA	Troy Thomas Munn	Marjorie Marie Munn	Signed	(1) The employer does not elect the employers’ liability coverage.	Troy Munn	Troy@munnentllc.com	Owner	Clear Lake	Cerro Gordo	Iowa	Troy Thomas Munn	Marjorie Marie Munn	Signed
780	2021-12-06 10:45	Anonymous (not verified)	172.83.21.144	Munn Enterprises LLC	Limited Liability Company	118 14th Avenue South	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.	2021-12-06	Troy T Munn	Troy@munnentllc.con	Clear lake	Cerro Gordo	Iowa	Douglas A Munn	Marjorie Marie Munn	Signed	(1) The employer does not elect the employers’ liability coverage.	Troy Thomas Munn	troy@munnentllc.com	Same	Clear Lake	Cerro Gordo	Iowa	Douglas A Munn	Marjorie Marie Munn	Signed
1501	2023-03-07 11:27	Anonymous (not verified)	94.188.205.167	Adriene Dangler	Proprietorship	2400 South Shore Dr Clear Lake, IA 50428	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.	2022-04-14	Adrienne Dangler	darrele@ciains.biz	Clear Lake	Cerro Gordo	Iowa	Darrel Elsbernd	Chris Fye	Signed	(1) The employer does not elect the employers’ liability coverage.	Darrel Elsbernd	darrele@ciains.biz	agent	Clear Lake	Cerro Gordo	Iowa	Darrel Elsbernd	Chris Fye	Signed
1903	2023-11-13 09:08	Anonymous (not verified)	94.188.207.228	Christopher Stone	Proprietorship	2427 S Taft Ave Apt #8	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.	2023-11-10	Christopher Stone	darrele@ciains.biz	Iowa	Cerro Gordo	IA	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Christopher Stone	darrele@ciains.biz	self	Mason City	Cerro Gordo	Iowa	Chris Fye	Darrel Elsbernd	Signed
1907	2023-11-15 09:45	Anonymous (not verified)	94.188.205.168	Dan Taylor	Proprietorship	1422 State 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.	2023-11-15	Daniel Taylor	mailrunner1958@gmail.com	Mason City	Cerro Gordo	IA	Bob Smith	Dave Clark	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Taylor	mailrunner1958@gmail.com	employee	Mason City	Cerro Gordo	IA	Bob Smith	Dave Clark	Signed
466	2021-04-08 09:58	Anonymous (not verified)	216.81.153.249	Supreme Express Transport LLC	Limited Liability Company	609 Euclid Ave, Cherokee, IA 51012	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.	2021-04-10	Liana Gil	liana2702@gmail.com	Cherokee	Cherokee	Iowa	Leigh Laven	Jared Brashears	Signed	(1) The employer does not elect the employers’ liability coverage.	Liana Gill	liana2702@gmail.com	Owner	Cherokee	Cherokee	Iowa	Leigh Laven	Jared Brashears	Signed
1988	2024-01-16 15:22	Anonymous (not verified)	94.188.205.176	Harmons Home Services LLC	Limited Liability Company	605 w Cedar st, Cherokee, IA, 51012	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.	2024-01-16	Shawn Michael Harmon	harmonsheatingandair@gmail.com	Cherokee	Ia	United States	Shawn Harmon	Sara Harmon	Signed	(1) The employer does not elect the employers’ liability coverage.	Shawn Michael Harmon	Harmonsheatingandair@gmail.com	Self	Cherokee	Cherokee	IA	Shawn Harmon	Sara Harmon	Signed
2088	2024-03-12 10:44	Anonymous (not verified)	94.188.207.226	Elmer Henry Vicente Lopez	Proprietorship	1602 Court St Apt 2 Sioux City, IA 51105	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-01	Elmer Henry Vicente Lopez	vicenteelmer33@gmail.com	Sioux City	Woodbury	Iowa	Adrian Dominguez	Ronald Halverson	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron Halverson	ron@sppinsurance.com	independent contractor	Cherokee	Cherokee	IA	Elmer Henry Vicente Lopez	Ronald Halverson	Signed
2090	2024-03-12 14:16	Anonymous (not verified)	94.188.205.169	Oscar Sosa	Proprietorship	110 E Cherry St Cherokee, IA 51012	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.	2023-01-01	Oscar Sosa	oscarsosa@live.com	Cherokee	Cherokee	Iowa	Adrian Dominguez	Ronald Halverson	Signed	(1) The employer does not elect the employers’ liability coverage.	Ron Halverson	ron@sppinsurance.com	independent contractor	Cherokee	Cherokee	IA	Oscar Sosa	Ronald Halverson	Signed
2040	2024-02-08 10:35	Anonymous (not verified)	94.188.207.226	Storm Pro Solution	Limited Liability Company	1309 Coffeen Sheridan,wy 82801	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.	2024-02-08	Candis Henderson	Cneal@stormprosolution.com	Broadview	Chicago	Illinois	Chester Neal	Eric Henderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Candis Henderson	Cneal@stormprosolution.com	Self	Broadview	Chicago	Illinois	Chester neal	Eric Henderson	Signed
83	2020-02-28 12:55	Anonymous (not verified)	204.16.58.27	Baltes Trucking LLC	Limited Liability Company	203 N Gilmore Ave New Hampton IA 50659	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	Clinton Lee Baltes	clintbaltes@gmail.com	New Hampton	Chickasaw	Iowa	Tammy Robinson	Richard Kramer	Signed	(1) The employer does not elect the employers’ liability coverage.	Clinton Lee Baltes	clintbaltes@outlook.com	Owner	New Hampton	Chickasaw	Iowa	Tammy Robinson	Richard Kramer	Signed
497	2021-04-27 09:25	Anonymous (not verified)	204.153.176.147	SHANE HUCK	Proprietorship	1070 305TH STREET, NASHUA, IOWA 50658	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-27	SHANE HUCK	WOODHUCK@GMAIL.COM	NASHUA	CHICKASAW	IOWA	KIM LOECKLE	RACHEL SCHNEIDER	Signed	(1) The employer does not elect the employers’ liability coverage.	SHANE HUCK	WOODHUCK@GMAIL.COM	OWNER	NASHUA	CHICKASAW	IOWA	KIM LOECKLE	RACHEL SCHNEIDER	Signed
286	2020-10-21 18:32	Anonymous (not verified)	173.218.73.44	Bilyeu Underground LLC	Limited Liability Company	1136 W. Irene Ct. Nixa, MO 65714	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-21	Daniel Bilyeu	danielbilyeu@gmail.com	Nixa	Christian	Missouri	Gary George Bilyeu	Chad Anthony Charles	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Bilyeu	danielbilyeu@gmail.com	Owner	Nixa	Christian	Missouri	Gary George Bilyeu	Chad Anthony Charles	Signed
287	2020-10-21 18:35	Anonymous (not verified)	173.218.73.44	Bilyeu Underground LLC	Limited Liability Company	1136 W. Irene Ct. Nixa, MO 65714	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-21	Gary George Bilyeu	garygb1990@gmail.com	Sparta	Christian	Missouri	Daniel Bilyeu	Chad Anthony Charles	Signed	(1) The employer does not elect the employers’ liability coverage.	Gary George Bilyeu	garygb1990@gmail.com	Owner	Sparta	Christian	Missouri	Chad Anthony Charles	Daniel Bilyeu	Signed
288	2020-10-21 18:36	Anonymous (not verified)	173.218.73.44	Bilyeu Underground LLC	Limited Liability Company	1136 W. Irene Ct. Nixa, MO 65714	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-10-21	Chad Anthony Charles	y4ardgn0m3r@gmail.com	Nixa	Christian	Missouri	Gary George Bilyeu	Daniel Bilyeu	Signed	(1) The employer does not elect the employers’ liability coverage.	Chad Anthony Charles	y4ardgn0m3r@gmail.com	Owner	Nixa	Christian	Missouri	Gary George Bilyeu	Daniel Bilyeu	Signed
1110	2022-05-17 11:17	Anonymous (not verified)	64.33.230.163	Jed Hansen	Proprietorship	1626 Airport Dr	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.	2022-05-17	Jed Douglas Hansen	hangar.8@hotmail.com	Clark	Clark	South Dakota	Jed Hansen	Jed Hansen	Signed	(1) The employer does not elect the employers’ liability coverage.	Jed Hansen	hangar.8@hotmail.com	Proprietor	Clark	Clark	South Dakota	Jed Hansen	Jed Hansen	Signed
1111	2022-05-17 11:18	Anonymous (not verified)	64.33.230.163	Jed Hansen	Proprietorship	1626 Airport Dr	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.	2022-05-17	Jed Douglas Hansen	hangar.8@hotmail.com	Clark	Clark	South Dakota	Jed Hansen	Jed Hansen	Signed	(1) The employer does not elect the employers’ liability coverage.	Jed Hansen	hangar.8@hotmail.com	Proprietor	Clark	Clark	South Dakota	Jed Hansen	Jed Hansen	Signed
1385	2022-12-08 18:45	Anonymous (not verified)	173.26.84.6	Fansco LLC	Limited Liability Company	620 2 nd Ave SE Cresco IOWA 52136	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.	2022-12-08	Arif Sheikh	Sheikha44@yahoo.com	Cresco	Howard	IOWA	Bibi Sheikh	Usman Sheikh	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Arif Sheikh	Sheikha44@yahoo.com	Relative	Henderson	Clark	Navada	Bibi Sheikh	Usman Sheikh	Signed
1053	2022-04-14 21:08	Anonymous (not verified)	50.83.192.136	John E Snyder JR	Proprietorship	1677 PACIFIC ST, MURRAY, IA 50174	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.	2022-04-14	John Snyder JR	jrsweldingia@gmail.com	MURRAY	Clarke	Iowa	Shelly Goslar	Dorene Short	Signed	(1) The employer does not elect the employers’ liability coverage.	John Snyder JR	jrsweldingia@gmail.com	Selg	MURRAY	Clarke	Iowa	Shelly Goslar	Dorene Short	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
1609	2023-04-26 11:58	Anonymous (not verified)	94.188.205.168	edwin gonzalez	Proprietorship	115 e ayers st 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.	2023-04-26	edwin gonzalez	lrestrada83@gmail.com	osceola	Clark	ia	Sheanah Wright	Derek Mullins	Signed	(1) The employer does not elect the employers’ liability coverage.	edwin gonzalez	lrestrada83@gmail.com	owner	osceola	clarke	ia	Sheanah Wright	Derek Mullins	Signed
1994	2024-01-23 14:35	Anonymous (not verified)	94.188.207.229	Josh Oswald	Proprietorship	505 Eisenhower Rd., 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.	2024-01-23	Josh Oswald	jjoswald47@gmail.com	Osceola	Clarke	Iowa	Douglas Eugene Miller	Elaine Lee	Signed	(1) The employer does not elect the employers’ liability coverage.	JOSHUA OSWALD	jjoswald47@gmail.com	Sole Proprietor	Osceola	Clarke	Iowa	Douglas Eugene Miller	Elaine Lee	Signed
1995	2024-01-23 15:08	Anonymous (not verified)	94.188.205.167	Spencer Abbott	Proprietorship	1358 170th Ave, Murray Iowa 50174	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.	2024-01-23	Spencer Abbott	sabbott1800@gmail.com	Murray	Clarke	Iowa	Juanita Yutzy	Elaine Lee	Signed	(1) The employer does not elect the employers’ liability coverage.	Spencer Abbott	sabbott1800@gmail.com	sole proprietor	Murray	Clarke	Iowa	Juanita Yutzy	Elaine Lee	Signed
32	2020-01-08 08:31	Anonymous (not verified)	199.120.118.90	BOBCATS LLC	Limited Liability Company	1860 505TH ST LINN GROVE 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.	2019-11-18	CHRIS AXDAHL	CHRISAXDAHLINC@HOTMAIL.COM	LINN GROVE	CLAY	IOWA	TESSA L STEFFEN	JOSEPH E ZENKOVICH	Signed	(1) The employer does not elect the employers’ liability coverage.	CHRIS AXDAHL	CHRISAXDAHLINC@HOTMAIL.COM	OWNER	LINN GROVE	CLAY	IOWA	TESSA L STEFFEN	JOSEPH E ZENKOVICH	Signed
44	2020-01-28 12:55	Anonymous (not verified)	173.24.181.211	AMANDA FIEDLER	Proprietorship	10 5TH AVE NW FOSTORIA, IA 51340	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.	2020-01-28	AMANDA FIEDLER	JOEL@WALKERINSURANCEIA.COM	FOSTORIA	CLAY	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	AMANDA FIEDLER	JOEL@WALKERINSURANCEIA.COM	OWNER	FOSTORIA	CLAY	IA	JOSPH THOMAS LORING	TAMI SUE KLEIN	Signed
665	2021-10-06 09:22	Anonymous (not verified)	192.96.173.171	Michael Childers	Proprietorship	21 N.6th street savanna Illinois	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.	2021-10-06	Michael Childers	peddler73@hotmail.com	Savanna	Carroll	Illinois	Brandy arnold	Jordan nisiewicz	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas city	Clay	Mo	Jordan nisiewicz	Brandy arnold	Signed
763	2021-11-22 12:32	Anonymous (not verified)	63.229.189.35	Adam Dotson Tiling	Proprietorship	324 E 14th Street, Spencer, IA 51301	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.	2021-11-22	Adam Dotson	adamdotson1975@gmail.com	Spencer	Clay	Iowa	Abigail Miles	Alex Miles	Signed	(1) The employer does not elect the employers’ liability coverage.	Adam Dotson	adamdotson1975@gmail.com	Self	Spencer	Clay	Iowa	Abigail Miles	Alex Miles	Signed
770	2021-11-22 18:17	Anonymous (not verified)	192.82.97.13	Paul Wire	Proprietorship	1005 25th Street SW, Spencer, IA 51301	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.	2021-11-22	Paul Wire	gizzmochee@gmail.com	Spencer	Clay	IA	Lori Wire	Abigail Miles	Signed	(1) The employer does not elect the employers’ liability coverage.	Paul Wire	gizzmochee@gmail.com	Self	Spencer	Clay	IA	Lori Wire	Abigail Miles	Signed
772	2021-11-23 10:13	Anonymous (not verified)	63.229.189.35	Hubbards Cupboards	Proprietorship	713 2nd Ave SW, Spencer, IA 51301-5603	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.	2021-11-23	James Hubbard	abigail@rickmilesartisans.com	Spencer	Clay	Iowa	Abigail Miles	Alex Miles	Signed	(1) The employer does not elect the employers’ liability coverage.	James Hubbard	abigail@rickmilesartisans.com	Self	Spencer	Clay	Iowa	Abigail Miles	Alex Miles	Signed
788	2021-12-14 09:36	Anonymous (not verified)	162.250.36.34	Sylvester Enterprises, LLC	Limited Liability Company	4800 Sylvester Rd. Webb, Ia. 51366	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.	2021-12-14	Tim Christian Sylvester	isusly89@gmail.com	Webb	Clay	Iowa	Dennis Dwain Somers	LInda Elayne Somers	Signed	(1) The employer does not elect the employers’ liability coverage.	Tim Christian Sylvester	slyenterprisesllc20@gmail.com	Owner	Webb	Clay	Iowa	Dennis Dwain Somers	Linda Elayne Somers	Signed
789	2021-12-14 09:39	Anonymous (not verified)	162.250.36.34	Sylvester Enterprises, LLC	Limited Liability Company	4800 Sylvester Rd. Webb, Iowa 51366	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.	2021-12-14	Christian Grant Sylvester	slyfarms97@gmail.com	Webb	Clay	iowa	Dennis Dwain Somers	LInda Elayne Somers	Signed	(1) The employer does not elect the employers’ liability coverage.	Tim Christian Sylvester	slyenterprisesllc20@gmail.com	Owner	Webb	Clay	Iowa	Dennis Dwain Somers	Linda Elayne Somers	Signed
1086	2022-05-03 12:32	Anonymous (not verified)	173.31.148.43	SHAWN BAIRD	Proprietorship	PO BOX 44 307 MEADOW ST ROYAL, IA 51357	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-02	SHAWN BAIRD	FLOORMAN3872@GMAIL.COM	ROYAL	CLAY	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed	(1) The employer does not elect the employers’ liability coverage.	SHAWN BAIRD	FLOORMAN3872@GMAIL.COM	SELF	ROYAL	CLAY	IA	JOSEPH THOMAS LORING	TAMI SUE KLEIN	Signed
1305	2022-09-13 14:28	Anonymous (not verified)	166.181.82.226	MarDe's construction	Limited Liability Company	5381 16th Ave la porte city ia 50651	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-13	Dean Michael John Martells	deanmartells@gmail.com	La porte city	Benton	Ia	Sonya Alfreda Mounlavong	Cameron Michael Martells	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Regional recruiter	Kansas city, mo	Clay	Missouri	Jordan Nisiewicz	Jordan Loyd	Signed
1306	2022-09-13 15:50	Anonymous (not verified)	96.31.1.206	LUCIO PAINTING	Proprietorship	818 W 4TH ST SPENCER, IA 51301	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-09-06	LUCIO PENA	joel@walkerinsuranceia.com	SPENCER	CLAY	IOWA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	LUCIO PENA	joel@walkerinsuranceia.com	SELF	SPENCER	CLAY	IA	JOSEPH THOMAS LORING	JENNIFER JANET YOUNGWIRTH	Signed
1339	2022-10-18 14:14	Anonymous (not verified)	97.125.41.64	Juan Buenrostro	Proprietorship	2122 E 39th st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-18	Juan Buenrostro	juanjosebuenrostro@gmail.com	Des Moines	Polk	IA	Juan Buenrostro	Kelly gonzalez buenrostro	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan nisiewicz	jnisiewicz@leafhome.com	Regional recruiter	Kansas City	Clay	Missouri	Jordan nisiewicz	Jordan loyd	Signed
1344	2022-10-25 13:09	Anonymous (not verified)	69.76.241.21	Tom Cole	Proprietorship	742 Mill St. Council, IA 51503	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-25	Tom Cole	tcoleg1963@gmail.com	Council Bluffs, IA	Pottawattamie County, IA	Iowa	Jordan Nisiewicz	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Regional Recruiter	Kansas City, MO	Clay	Missouri	Jordan Nisiewicz	Jordan Loyd	Signed
1363	2022-11-08 11:37	Anonymous (not verified)	69.76.241.21	S&M Veteran Contracting	Proprietorship	1529 E Ave 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.	2022-11-08	Shane Little	smveterancontracting@gmail.com	Cedar Rapids	Linn County	Iowa	Jordan Nisiewicz	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Regional Recruiter	Kansas City	Clay	MO	Jordan Loyd	Joshua Lafond	Signed
1378	2022-11-21 15:12	Anonymous (not verified)	136.34.59.85	Jake Jones	Proprietorship	203 9th Ave. Colona, Il 61241	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.	2022-11-21	Jake Jones	jmjones807@gmail.com	Colona	Henry	Illinois	Jordan Nisiewicz	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Regional Recruiter	Kansas City	Clay	Missouri	Jordan Loyd	Daniel Neal	Signed
1391	2022-12-12 11:13	Anonymous (not verified)	136.35.255.41	Snyder Roofing	Proprietorship	2343 ridge trail ne cedar rapids ia 52402	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-12-12	Craig Snyder	snyderroofingcr@gmail.com	Cedar Rapids	Linn county	Iowa	Jordan Loyd	Charles Wood	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Charles Wood	Jordan Loyd	Signed
1429	2023-01-25 13:43	Anonymous (not verified)	136.35.255.41	J&D Renovations	Proprietorship	114 2nd St. Carbon Cliff, IL 61239	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-01-25	Donald Lane	jdrenovations309@gmail.com	Carbon Cliff, IL	Rock Island County	Illinois	Jordan Nisiewicz	Cody Dunbar	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Jordan Loyd	Cody Dubar	Signed
1445	2023-02-08 14:56	Anonymous (not verified)	94.188.207.225	Spencer Imaging Center, LLC	Limited Liability Company	710 S. Grand 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.	2023-02-08	William Jay Muller	mullerwilliam@hotmail.com	Spencer	Clay	IA	Shanna Marie Kooker	Chad A Roemeling	Signed	(1) The employer does not elect the employers’ liability coverage.	Alexander Pruitt	apruitt@ncn.net	Partner	Spencer	Clay	IA	Shanna Marie Kooker	Chad A Roemeling	Signed
1453	2023-02-14 07:19	Anonymous (not verified)	94.188.207.230	Milton Gray	Proprietorship	255 10th Ave., Marion, IA 52302, US	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-13	Milton Gray	miltongray23@gmail.com	Marion, IA	Linn	Iowa	Jordan Nisiewicz	Charles Wood	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	MO	Charles Wood	Steven Geisler	Signed
1454	2023-02-14 09:34	Anonymous (not verified)	94.188.207.227	Spencer Imaging Center, LLC	Limited Liability Company	710 S. Grand Ave., Spencer, IA 51301	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.	2023-02-14	Alexander Pruitt	apruitt@ncn.net	Spencer	Clay	IA	Shanna Marie Kooker	Chad Roemeling	Signed	(1) The employer does not elect the employers’ liability coverage.	William Muller	mullerwilliam@hotmail.com	Co owner	Spencer	Clay	IA	Shanna Marie Kooker	Chad Roemeling	Signed
1513	2023-03-13 06:54	Anonymous (not verified)	94.188.205.169	Tyler Ankney	Proprietorship	1250 A Avenue, Marion, IA 52302, 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.	2023-03-13	Tyler Ankney	T_james55@ahoo.com	Marion	Linn County	Iowa	Jordan Nisiewicz	Steve Gisler	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Jordan Loyd	Steve Gisler	Signed
1563	2023-04-11 08:49	Anonymous (not verified)	94.188.205.168	Ibrahim Sehic	Proprietorship	4052 Lafayette Rd, Evansdale, IA 50707	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.	2023-04-11	Ibrahim Sehic	bacosidig@gmail.com	Evansdale, IA	Black Hawk County	Iowa	Jordan Nisiewicz	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Jordan Loyd	Warren Crow	Signed
1564	2023-04-11 09:15	Anonymous (not verified)	94.188.205.174	Darryl Kinnard	Proprietorship	60 Miller Avenue Southwest #13, Cedar Rapids, IA 52404, 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.	2023-04-11	Darryl Kinnard	darryl186d@icloud.com	Cedar Rapids	Linn County	Iowa	Jordan Nisiewicz	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Jordan Loyd	Robert Snyder	Signed

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