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:
411	2021-02-22 15:58	Anonymous (not verified)	173.24.190.134	The Willow Tree Garden Center	Limited Liability Company	2103 19rh 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.	2021-02-22	Erica Janssen	mrjanz13@gmail.com	Emmetsburg	Palo Alto	Iowa	Marilee Lace	Candie Clark	Signed	(1) The employer does not elect the employers’ liability coverage.	Erica Janssen	mrjanz13@gmail.com	Member of LLC	Emmetsburg	Palo Alto	Iowa	Marilee Lace	Candie Clark	Signed
1243	2022-08-04 21:00	Anonymous (not verified)	173.24.221.228	Foreman's Tile Creations	Proprietorship	1412 Franklin 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.	2022-08-04	Sole Proprietor	fudog4man@gmail.com	Center Point	Linn	IA	Aaron Foreman	Aaron Foreman	Signed	(1) The employer does not elect the employers’ liability coverage.	Aaron Foreman	fudog4man@gmail.com	I am the Employer	Center Point	Linn	IA	Aaron Foreman	Aaron Foreman	Signed
511	2021-05-10 17:53	Anonymous (not verified)	173.24.231.27	QSC Snow Removal	Proprietorship	1211 Carroll Boone 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.	2021-05-10	Vincent A Kaylor	phenox32@gmail.com	Boone	IA	United States	Lori Harvey	Doug Robertson	Signed	(1) The employer does not elect the employers’ liability coverage.	Vincent A Kaylor	phenox32@gmail.com	self	Boone	IA	United States	Lori Harvey	Doug Robertson	Signed
37	2020-01-16 15:26	Anonymous (not verified)	173.24.236.134	Eric Krueger	Proprietorship	406 NE Oak Dr. Ankeny, IA 50021	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-16	Eric Lucas Krueger	erickrugs@gmail.com	Ankeny	Polk	Iowa	Emily Marie Krueger	Roberty William Krueger	Signed	(1) The employer does not elect the employers’ liability coverage.	Eric Krueger	erickrugs@gmail.com	self	Ankeny	Polk	Iowa	Emily Marie Krueger	Robert William Krueger	Signed
1410	2023-01-06 10:58	Anonymous (not verified)	173.25.103.95	Bryce Kenworthy	Proprietorship	155 NW Maple St Elkhart IA 50073	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.	2023-01-06	Bryce Kenworthy	midwest.fencingandconstruction@gmail.com	Elkhart	Polk	Iowa	Kevin Corn	Nicole Almburg	Signed	(1) The employer does not elect the employers’ liability coverage.	Bryce Kenworthy	midwest.fencingandconstruction@gmail.com	Owner	Elkhart	Polk	Iowa	Kevin Corn	Nicole Almburg	Signed
565	2021-07-08 13:42	Anonymous (not verified)	173.25.132.255	Communications Construction Services LLC	Limited Liability Company	1315 East 38th 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.	2021-07-08	John McCann Jr	communicationconstructionllc@gmail.com	Des Moines	IA	United States	Laura McCann	David Garza	Signed	(1) The employer does not elect the employers’ liability coverage.	Laura McCann	communicationconstructionllc@gmail.com	spouse	Des Moines	IA	United States	John J McCann Jr	David Christopher Garza III	Signed
333	2020-12-05 08:57	Anonymous (not verified)	173.25.143.97	Groen Pediatric Consulting	Limited Liability Company	1206 NE 31ST ST Ankeny, IA 50021	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-01	Amy Groen	dramygroen@yahoo.com	Ankeny	Iowa	United States	Daniel Martin	Anita Anderson	Signed	(1) The employer does not elect the employers’ liability coverage.	Amy Groen	dramygroen@yahoo.com	self	Ankeny	Iowa	United States	Kay Martin	Priscilla Putzier	Signed
616	2021-08-23 13:14	Anonymous (not verified)	173.25.153.19	Levon	Proprietorship	210 S 41st	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.	2021-08-23	Levon shheba	sheebalevon@gmail.com	West des Moines IA 50265	Polk county	IA	Alina sheeba	Delon sheeba	Signed	(1) The employer does not elect the employers’ liability coverage.	Levon sheeba	sheebalevon@gmail.com	Myself	West des Moines IA 50265	Polk county	IA	Alina sheeba	Delon sheeba	Signed
441	2021-03-18 16:20	Anonymous (not verified)	173.25.156.33	CYALCO AVIATION LLC	Limited Liability Company	3710 W. MILWAUKEE 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.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2021-03-18	WILLIAM A. VAN LENT	bvl@veridian.net	WEST DES MOINES	POLK	IOWA	ERIN MONFORT NELSON	COLE M. VAN LENT	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	WILLIAM A. VAN LENT	bvl@veridian.net	SAME	WEST DES MOINES	POLK	IOWA	ERIN MONFORT NELSON	COLE M. VAN LENT	Signed
1329	2022-10-10 10:55	Anonymous (not verified)	173.25.222.69	Eli's	Limited Liability Company	931 S Van Buren St Iowa City, Iowa 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.	2022-10-10	Elijah Ortiz	eortiz15@gmail.com	Iowa City	Johnson	Iowa	Erica Mason	Bryan Horrell	Signed	(1) The employer does not elect the employers’ liability coverage.	Elijah Ortiz	eortiz15@gmail.com	Proprietor	Iowa City	Johnson	Iowa	Erica Mason	Bryan Horrell	Signed
351	2021-01-06 16:20	Anonymous (not verified)	173.25.23.170	Eric Krueger	Proprietorship	406 NE Oak Dr. Ankeny, IA 50021	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-07	Eric Lucas Krueger	erickrugs@gmail.com	Ankeny	Polk	Iowa	Emily Marie Krueger	Robert William Krueger	Signed	(1) The employer does not elect the employers’ liability coverage.	Eric Lucas Krueger	erickrugs@gmail.com	self	Ankeny	Polk	Iowa	Emily Marie Krueger	Robert William Krueger	Signed
70	2020-02-19 19:30	Anonymous (not verified)	173.25.39.58	Central Iowa Portable Welding	Limited Liability Company	708 S Main St. Woodward Ia, 50276	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.	2020-02-19	Eric Lendt	Eric@weldiowa.com	Woodward	America	IA	Chris Lendt	Central Iowa Portable Welding	Signed	(1) The employer does not elect the employers’ liability coverage.	Central Iowa Portable Welding	Eric@weldiowa.com	Himself	woodward	American	IA	Central Iowa Portable Welding	Central Iowa Portable Welding	Signed
118	2020-04-13 11:48	Anonymous (not verified)	173.26.152.222	Society of St. Vincent de Paul, District Council of Waterloo Iowa,Inc	Limited Liability Company	320 Broadway St PO Box 2727 Waterloo IA 50704	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.	2020-04-14	Joseph D. Sobczyk	joczyk@aol.com	Cedar Falls	Black Hawk	Iowa	George W. Karnick	Glynis R. Worthington	Signed	(1) The employer does not elect the employers’ liability coverage.	Joseph D. Sobczyk	joczyk@aol.com	self	Cedar Falls	Black Hawk	Iowa	George W. Karnick	Glynis R. Worthington	Signed
1349	2022-10-28 12:37	Anonymous (not verified)	173.26.153.59	spotlight drywall	Proprietorship	1001 7th 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.	2022-06-01	paul woods	spotlight.2008@hotmail.com	Grundy Center	Ia	United States	thuy do	jaden do	Signed	(1) The employer does not elect the employers’ liability coverage.	thuy do	spotlight.2008@hotmail.com	bookeeper	Grundy Center	Ia	United States	thuy do	jaden do	Signed
362	2021-01-14 12:15	Anonymous (not verified)	173.26.157.255	Shear Bliss Pet Salon	Limited Liability Company	824 Ansborough Ave. Waterloo, IA 50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-14	Sarah K Bebee	shearblisspet@aol.com	Hudson	Black Hawk	Iowa	Janice Rae Bebee	Danny J Bebee	Signed	(1) The employer does not elect the employers’ liability coverage.	Sarah Bebee	shearblisspet@aol.com	self	Hudson	Black Hawk	Iowa	Janice Rae Bebee	Danny J Bebee	Signed
363	2021-01-14 12:17	Anonymous (not verified)	173.26.157.255	Shear Bliss Pet Salon	Limited Liability Company	824 Ansborough Ave. Waterloo, IA 50701	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-14	Melissa Kay Herold	shearblisspet@aol.com	Cedar Falls	Black Hawk	Iowa	Janice Rae Bebee	Danny J Bebee	Signed	(1) The employer does not elect the employers’ liability coverage.	Meliss Kay Herold	shearblisspet@aol.com	self	Cedar Falls	Black Hawk	Iowa	Janice Rae Bebee	Danny J Bebee	Signed
946	2022-03-04 10:43	Anonymous (not verified)	173.26.213.159	InTuition Painting & Design	Proprietorship	2244 East 46th Place Davenport Iowa, 52807	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-04	Brian J Bourke	brianbourke@mediacombb.net	Davenport	Scott	IA	Anna E. Bourke	Nicole K. Bourke	Signed	(1) The employer does not elect the employers’ liability coverage.	Brian Bourke	intuitionpainting@mediacombb.net	Self	Davenport Iowa	Scott	Iowa	Nicole K. Bourkeq	Anna E. Bourke	Signed
1386	2022-12-09 08:35	Anonymous (not verified)	173.26.84.6	Fansco LLc DBA Cresco motel	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.	(1) I am not electing the employers’ liability coverage.	2022-12-09	Arif Sheikh	Sheikha44@yahoo.com	Cresco	Howard	IOWA	Bibi Sheikh	Usman Sheikh	Signed	(1) The employer does not elect the employers’ liability coverage.	Arif Sheikh	Sheikha44@yahoo.com	Self	CRESCO	Howard	IOWA	Bibi Sheikh	Usman Sheikh	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
950	2022-03-04 19:58	Anonymous (not verified)	173.26.94.212	JRH Services	Limited Liability Company	525 Third 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.	2022-03-04	Joshua Blakeslee	jrhservicesiowa@outlook.com	Evansdale	Blackhawk	IA	Nicole Blakeslee	Lois Riggleman	Signed	(1) The employer does not elect the employers’ liability coverage.	Joshua Blakeslee	jrhservicesiowa@outlook.com	Owner	Evansdale	Blackhawk	IA	Nicole Blakeslee	Lois Riggleman	Signed
163	2020-05-20 11:58	Anonymous (not verified)	173.27.1.111	David	Proprietorship	4023 E 28th st 50317	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-05-20	David Ortiz	jdiconstrucction@gmail.com	Des Moines	Polk County	Iowa	Erika Olague	Jieldh Ortiz-Olague	Signed	(1) The employer does not elect the employers’ liability coverage.	David Ortiz	jdiconstrucction@gmail.com	JDI Construction	Des Moines	Polk County	Iowa	Erika Olague	Jieldh Ortiz-Olague	Signed
879	2022-01-31 14:26	Anonymous (not verified)	173.27.146.201	Premier Window Cleaning LLC	Limited Liability Company	420 E GRANGER 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.	2022-01-31	Frank Viola	premierofiowa@gmail.com	DES MOINES	IA	United States	Ron Reynolds	Chris Greco	Signed	(1) The employer does not elect the employers’ liability coverage.	Frank Viola	premierofiowa@gmail.com	my self	DES MOINES	IA	United States	Ron Reynolds	Chris Greco	Signed
1038	2022-04-11 09:43	Anonymous (not verified)	173.27.156.183	JABS Construction/Finish	Limited Liability Company	543 10th Ave. S.	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.	2022-04-11	Roberto John Henrickson	henricksonroberto10@gmail.com	Clinton	IA	United States	Jordan Nisiewicz	Cody Dunbar	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay County	Missouri	Roberto J Henrickson	Cody Dunbar	Signed
988	2022-03-21 10:40	Anonymous (not verified)	173.27.156.183	JABS Construction/Finish	Limited Liability Company	543 10th Ave. S.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-20	Roberto John Henrickson	henricksonroberto10@gmail.com	Clinton	IA	United States	N/A	N/a	Signed	(1) The employer does not elect the employers’ liability coverage.	Roberto John Henrickson	henricksonroberto10@gmail.com	Owner	Clinton	IA	United States	N/A	N/A	Signed
989	2022-03-21 10:40	Anonymous (not verified)	173.27.156.183	JABS Construction/Finish	Limited Liability Company	543 10th Ave. S.	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-20	Roberto John Henrickson	henricksonroberto10@gmail.com	Clinton	IA	United States	N/A	N/a	Signed	(1) The employer does not elect the employers’ liability coverage.	Roberto John Henrickson	henricksonroberto10@gmail.com	Owner	Clinton	IA	United States	N/A	N/A	Signed
572	2021-07-13 09:59	Anonymous (not verified)	173.27.17.202	David Lochner	Proprietorship	866 40th ave Bettendorf Iowa 52722	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-13	David Lochner	jnagel@leafhome.com	Dubuque	Dubuque	Iowa	Jacob Nagel	Shawn Cowell	Signed	(1) The employer does not elect the employers’ liability coverage.	David Lochner	jnagel@leafhome.com	Self	Dubuque	Dubuque	Iowa	Jacob Nagel	Shawn Cowell	Signed
574	2021-07-14 10:43	Anonymous (not verified)	173.27.17.202	Maxwell Taylor	Proprietorship	618 east Colorado St. Davenport Iowa 52803	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-14	Maxwell Taylor	maxwelltaylor33@icloud.com	Davenport	Scott	Iowa	Jacob Nagel	Ty Reindl	Signed	(1) The employer does not elect the employers’ liability coverage.	Maxwell Taylor	maxwelltaylor33@icloud.com	Self	Davenport	Scott	Iowa	Jacob Nagel	Ty Reindl	Signed
1227	2022-07-26 09:20	Anonymous (not verified)	173.27.17.3	LeafFilter North LLC	Proprietorship	866 40th Ave bettendorf IA 52722	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-26	Craig Stang	stangcraig@gmail.com	Moline	Rock island	IL	Cody Dunbar	Tiffani Branham	Signed	(1) The employer does not elect the employers’ liability coverage.	LeafFilter North LLC	cdunbar@leaffilter.com	Install manager	Bettendorf	Iowa	United States	Cody dunbar	Tiffani Branham	Signed
1218	2022-07-21 10:55	Anonymous (not verified)	173.27.17.3	LeafFilter North LLC	Proprietorship	Bettendorf	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-21	Craig Stang	stangcraig@gmail.com	Silvis	Rock island	IL	Cody Dunbar	Tiffani Branham	Signed	(1) The employer does not elect the employers’ liability coverage.	LeafFilter North LLC	cdunbar@leaffilter.com	Install manager	Bettendorf	Iowa	United States	Cody dunbar	Tiffani Branham	Signed
853	2022-01-24 08:45	Anonymous (not verified)	173.27.193.218	Matt ruble	Limited Liability Company	808 Grandview ave Des Moines Iowa 50316	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.	2022-01-23	Matthew ruble	gmddetailing2012@gmail.com	Des Moines	Polk	Iowa	Matt Ruble	Matt Ruble	Signed	(1) The employer does not elect the employers’ liability coverage.	Matt Ruble	gmddetailing2012@gmail.com	Self	Des Moines	Polk	Iowa	Matt Ruble	Matt Ruble	Signed
686	2021-10-20 18:43	Anonymous (not verified)	173.27.196.168	Royal Flooring	Proprietorship	11801 Hickman Rd Urbandale, IA 50323 United States	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-20	Joel Cisneros	auroraramos476@gmail.com	Des Moines	Polk county	Iowa	Aurora Cisneros	Maria Arroyo	Signed	(1) The employer does not elect the employers’ liability coverage.	Royal Flooring	cisnerostile476@gmail.com	Employee	Clive	Dallas	Iowa	Aurora Cisneros	Maria Arroyo	Signed
953	2022-03-07 16:13	Anonymous (not verified)	173.27.196.168	Joel Cisneros	Proprietorship	721 e madison ave Des Moines Iowa 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.	2022-03-07	Joel Cisneros	cisnerostile476@gmail.com	Des monies	Polk county	Iowa	Aurora Cisneros	Romualda Ramos	Signed	(1) The employer does not elect the employers’ liability coverage.	Joel Cisneros	cisnerostile476@gmail.com	Employee	Des Moines	Polk	Iowa	Aurora Cisneros	Romualda Ramos	Signed
468	2021-04-12 14:54	Anonymous (not verified)	173.27.224.230	PCI Turf LLC	Limited Liability Company	1313 N Grant St. Knoxville, IA 50138	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.	2021-04-12	Ryan Trout	rtrout22@yahoo.com	Knoxville	Marion	Iowa	Joseph Durham	Carson Peterson	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Trout	pci.turf@yahoo.com	Self- owner/operator	Knoxville	Marion	Iowa	Joseph Durham	Carson Peterson	Signed
1146	2022-06-07 11:51	Anonymous (not verified)	173.27.226.177	Evans Endeavors LLC	Limited Liability Company	513 N Roche 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.	2022-06-07	Cody Evans	evansendeavor@gmail.com	Knoxville	Marion	Iowa	Erin Six	Carl stoffer	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody Evans	evansendeavor@gmail.com	Myself	Knoxville	Marion	Iowa	Erin six	Carl Stoffer	Signed
996	2022-03-22 23:37	Anonymous (not verified)	173.27.235.109	patriot t services	Proprietorship	205 park st carlisle , ia 50047	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-22	TRAVIS KEENEY	knytrav@aol.com	carlisle	warren	iowa	james Ren	Jesse Parker	Signed	(1) The employer does not elect the employers’ liability coverage.	Travis Keeney	knytrav@aol.com	myself	carlisle	warren	iowa	james ren	jesse parker	Signed
231	2020-08-13 18:22	Anonymous (not verified)	173.27.28.18	Kelley Contracting	Proprietorship	115 Pinecrest Circle Elk Run Heights, 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.	2020-08-13	Chad Kelley	chadkelley22@gmail.com	Elk Run Heights	Black Hawk	Iowa	Jack Kelley	Jennifer Kelley	Signed	(1) The employer does not elect the employers’ liability coverage.	Kelley Contracting	chadkelley22@gmail.com	Self	Elk Run Heights	Black Hawk	Iowa	Jack Kelley	Jennifer Kelley	Signed
112	2020-04-07 12:16	Anonymous (not verified)	173.27.33.108	Josh Alley Siding	Proprietorship	205 N Oak St. Davis City, IA 50065	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.	2018-04-10	Joshua H. Alley	alley.josh@yahoo.com	Davis City	Decatur	Iowa	Joe Fitzgerald	Steve Young	Signed	(1) The employer does not elect the employers’ liability coverage.	Josh Alley Siding	alley.josh@yahoo.com	Owner	Davis City	Decatur	Iowa	Joe Fitzgerald	Steve Young	Signed
113	2020-04-07 12:30	Anonymous (not verified)	173.27.33.108	Aarron Alley	Proprietorship	101 S Teale 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.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2018-05-15	Aarron Alley	aarronalley10@yahoo.com	Davis City	Decatur	Iowa	Joe Fitzgerald	Steve Young	Signed	(1) The employer does not elect the employers’ liability coverage.	Aarron Alley	aarronalley10@yahoo.com	Owner	Davis City	Decatur	Iowa	Joe Fitzgerald	Steve Young	Signed
308	2020-11-08 09:17	Anonymous (not verified)	173.27.33.108	Aarron Alley	Proprietorship	101 S Teale St. Davis City, 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.	2019-11-01	Aarron Alley	aarronalley10@yahoo.com	Davis City	Decatur	Iowa	Joe Fitzgerald	Steve Young	Signed	(1) The employer does not elect the employers’ liability coverage.	Aarron Alley	aarronalley10@yahoo.com	Owner	Davis City	Decatur	Iowa	Joe Fitzgerald	Steve Young	Signed
251	2020-09-08 17:00	Anonymous (not verified)	173.27.45.95	Peerless Construction, LLC	Limited Liability Company	4718 E 49th 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.	2020-09-08	Grant Jipp	grant.peerless@gmail.com	Davenport	Scott	Iowa	Dan Knight	Bridget Knight	Signed	(1) The employer does not elect the employers’ liability coverage.	Grant Jipp	grant.peerless@gmail.com	Owner	Davenport	Scott	Iowa	Dan Knight	Bridget Knight	Signed
887	2022-02-03 14:05	Anonymous (not verified)	173.27.49.231	Jade Mallicoat coaching	Limited Liability Company	1318 se linn st	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-03	Jade Mallicoat	jade.mallicoat@gmail.com	Boone	Boone	Iowa	Cord Anderson	Mike Anderson	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Jade mallicoat	jade.mallicoat@gmail.com	Myself	Boone	Boone	Iowa	Cord Anderson	Mike Anderson	Signed
232	2020-08-16 11:28	Anonymous (not verified)	173.27.57.39	Landeros & Sons Construction, Inc	Limited Liability Partnership	1636 19th Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-08-16	Fernando Landeros	fland1983@gmail.com	Moline	Rock Island	Illinois	Adrian Landeros	Emanuel Landeros	Signed	(1) The employer does not elect the employers’ liability coverage.	Emanuel Landeros	fland1983@gmail.com	Brother	Moline	Rock Island	Illinois	Adrian Landeros	Emanuel Landeros	Signed
907	2022-02-09 08:59	Anonymous (not verified)	173.28.0.37	Rusty K5 LLC	Limited Liability Company	804 SW Cherry St Ankeny, IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-09	Kristy Briles	kristyabriles@gmail.com	Des Moines	Polk	IA	Stephanie Seymour	Sue Briles	Signed	(1) The employer does not elect the employers’ liability coverage.	Kristy Briles	kristyabriles@gmail.com	Owner	Des moines	Polk	IA	50313	Sue Briles	Signed
906	2022-02-09 08:57	Anonymous (not verified)	173.28.0.37	CAB Holdings LLC	Limited Liability Company	804 SE Cherry ST Ankeny, IA 50023	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-09	Kristy Briles	kristyabriles@gmail.com	Des Moines	Polk	IA	Stephanie Seymour	Sue Briles	Signed	(1) The employer does not elect the employers’ liability coverage.	Kristy Briles	kristyabriles@gmail.com	owner	Des Moines	Polk	IOwa	Stephanie Seymour	Sue Briles	Signed
433	2021-03-12 20:47	Anonymous (not verified)	173.28.1.65	HomeTeam painting llc	Limited Liability Company	3810 Amherst 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.	2021-03-12	Johnny ollin	johnnyollin@gmail.com	DesMoines	Polk	IOWA	David Carney	Chad Winslow	Signed	(1) The employer does not elect the employers’ liability coverage.	Johnny ollin	johnnyollin@gmail.com	Myself	DesMoines	Polk	IOWA	David Carney	Chad Winslow	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
193	2020-06-24 11:13	Anonymous (not verified)	173.28.196.82	Gray Nation LLC DBA Gray Goat Tattoo	Limited Liability Company	116 N 1st Street West Branch, Iowa 52358-9663	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2020-06-24	Elizabeth Gray	beth.gray516@gmail.com	West Branch	Cedar	Iowa	Luis Ordenana	Don Naugthon	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Elizabeth Gray	beth.gray516@gmail.com	LLC Member	West Branch	Cedar	Iowa	Luis Ordenana	Don Naughton	Signed
376	2021-01-26 11:14	Anonymous (not verified)	173.28.210.45	Cross Medical Lab, L.L.P	Limited Liability Partnership	500 E Market St 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.	2021-01-26	Aaron Klein	lhavel_23@gmail.com	Iowa City	Johnson	Iowa	Ashley Lee	Dan Wegman	Signed	(1) The employer does not elect the employers’ liability coverage.	Lori Havel	lhavel_23@gmail.com	Office Manager	Iowa CIty	Johnson	IA	Ashley Lee	Dan Wegman	Signed
33	2020-01-09 15:57	Anonymous (not verified)	173.28.28.57	FALCON PRIDE PROPERTIES LLC	Limited Liability Company	1401 HWY 57 PARKERSBURG, IA 50665	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2019-12-13	TODD THOMAS	todd@wimcoach.com	PARKERSBURG	BUTLER	IA	CHAD CAMPBELL	ROXANNE KOLDER	Signed	(1) The employer does not elect the employers’ liability coverage.	TODD THOMAS	todd@wimcoach.com	SELF	PARKERSBURG	BUTLER	IA	CHAD CAMPBELL	ROXANNE KOLDER	Signed
129	2020-04-24 15:28	Anonymous (not verified)	173.28.28.57	Michael Jansen	Proprietorship	108 6th Street, Parkersburg, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-10	Michael G Jansen	cmins_re@mchsi.com	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael G Jansen	cmins_re@mchsi.com	Self	Parkersburg	Butler	Iowa	Chad Campbell	Roxanne Kolder	Signed

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