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:
1736	2023-07-11 08:30	Anonymous (not verified)	94.188.207.228	Scornos Waukee LLC	Limited Liability Company	286 w hickman rd waukee iowa 50263	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-11	Liana Fatino	lfatino@yahoo.com	des moines	polk	iowa	Liana Fatino	Gary Fatino	Signed	(1) The employer does not elect the employers’ liability coverage.	Liana Fatino	lfatino@yahoo.com	owner	des moines	polk	IOWA	Liana Fatino	Gary Fatino	Signed
1735	2023-07-11 08:28	Anonymous (not verified)	94.188.207.229	LBN LLC	Limited Liability Company	1930 se 14th Des Moines Iowa 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-11	Gary Fatino	fatinomarketinggroup@yahoo.com	Des Moines	polk	Iowa	Liana Fatino	Gary Fatino	Signed	(1) The employer does not elect the employers’ liability coverage.	Gary Fatino	fatinomarketinggroup@yahoo.com	owner	des moines	polk	iowa	liana fatino	gary fatino	Signed
1734	2023-07-11 08:25	Anonymous (not verified)	94.188.207.226	LBN LLC	Limited Liability Company	1930 se 14th Des Moines Iowa 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-11	Liana Fatino	lfatino@yahoo.com	Des Moines	Polk	Iowa	Liana Fatino	Gary Fatino	Signed	(1) The employer does not elect the employers’ liability coverage.	Liana Fatino	lfatino@yahoo.com	owner	des moines	polk	Iowa	Liana Fatino	Gary Fatino	Signed
1733	2023-07-10 14:30	Anonymous (not verified)	94.188.205.177	Leaf home	Proprietorship	1595 Georgetown Rd., Hudson, OH 44236	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-10	Andrew Koske	aokoz_23@outlook.com	East Moline	IL	United States	Andrew Koske	Andrew Koske	Signed	(1) The employer does not elect the employers’ liability coverage.	Andrew Koske	aokoz_23@outlook.com	None	East Moline	IL	United States	Andrew Koske	Andrew Koske	Signed
1732	2023-07-10 13:22	Anonymous (not verified)	94.188.207.224	Jovan Guerrero	Proprietorship	2887 Jaden Lane Norwalk, Iowa 50211	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-10	Jovan Guerrero	deb@piciowa.com	Norwalk	Warren	Iowa	Debra Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Jovan Guerrero	deb@piciowa.com	self	Norwalk	Warren	Iowa	Debra Stratton	Kelly Denger	Signed
1731	2023-07-10 11:12	Anonymous (not verified)	94.188.207.228	Romer & Associates LLC	Limited Liability Company	433 Thomas Avenue, Maquoketa, IA 52060	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-10	Clay K Romer	connellsupply@aol.com	Maquoketa	Jackson	IA	Susan Croatt	Dave Stockham	Signed	(1) The employer does not elect the employers’ liability coverage.	Clay K Romer	connellsupply@aol.com	Owner/same	Maquoketa	Jackson	IA	Susan Croatt	Dave Stockham	Signed
1730	2023-07-09 23:39	Anonymous (not verified)	94.188.207.225	Steffens Constuction	Proprietorship	68222 Lansing Road, Wiota, IA 50274	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-07	Bradyn Richard Steffens	steffens4211@gmail.com	Wiota	Cass	Iowa	Katrina Sonntag	Chris Obrien	Signed	(1) The employer does not elect the employers’ liability coverage.	Audra Kelley Steffens	steffens4211@gmail.com	wife	Wiota	Cass	Iowa	Katrina Sonntag	Chris Obrien	Signed
1729	2023-07-09 15:33	Anonymous (not verified)	94.188.207.223	Melvin A mineros	Limited Liability Company	6209 Windsor dr des moines IA 50312	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-09	Melvin A mineros	minerosframing.llc@gmail.com	Des moines	Polk	IA	Orlando dominguez	Isaac salazar	Signed	(1) The employer does not elect the employers’ liability coverage.	Jaime leiva	jaime@boersmaninsurance.com	Agent	Des moines	Polk	IA	Narciso hidalgo	Balmore perez	Signed
1728	2023-07-08 10:48	Anonymous (not verified)	94.188.207.230	Lima Charlie LLC	Limited Liability Company	56066 257th 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.	2023-06-10	Larry Homan	larry@Lima-Charlie.biz	Glenwood	Iowa	United States	Erin Jenkins	Jeremy Jenkins	Signed	(1) The employer does not elect the employers’ liability coverage.	Larry Lee Homan	Larry@Lima-Charlie.biz	Owner	Glenwood	Iowa	United States	Erin Homan	Jeremy Jenkins	Signed
1727	2023-07-07 18:26	Anonymous (not verified)	94.188.205.169	D&E LLC DBA Kanesville Valley	Limited Liability Company	P.O. Box 337 Council Bluffs, IA, 51502	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-07	Edward Gregory	eddegregory@gmail.com	Council Bluffs	Pottawattamie	Iowa	Natasha Gregory	Stanley Gregory	Signed	(1) The employer does not elect the employers’ liability coverage.	Edward Gregory	eddegregory@gmail.com	Self	Council Bluffs	Pottawattamie	Iowa	Natasha Gregory	Stanley Gregory	Signed
1726	2023-07-07 18:22	Anonymous (not verified)	94.188.205.168	D&E LLC DBA Kanesville Valley	Limited Liability Company	P.O. Box 337 Council Bluffs, IA, 51502	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-07	Damien Joseph Shull	damienshull@gmail.com	Omaha	Douglas	Nebraska	Angela Shull	John Shull	Signed	(1) The employer does not elect the employers’ liability coverage.	Damien Joseph Shull	damienshull@gmail.com	Self	Omaha	Douglas	Nebraska	Angela Shull	John Shull	Signed
1725	2023-07-07 13:37	Anonymous (not verified)	94.188.205.167	Liana Fatino	Limited Liability Company	1930 se 14th des moines iowa 50321	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-07	Liana Fatino	lfatino@yahoo.com	des moines	USA	Iowa	Liana Fatino	Gary Fatino	Signed	(1) The employer does not elect the employers’ liability coverage.	Liana Fatino	lfatino@yahoo.com	wife	des moines	USA	iowa	Liana Fatino	Gary Fatino	Signed
1724	2023-07-06 19:34	Anonymous (not verified)	94.188.207.223	ALDO B. CANCINO HERNANDEZ	Proprietorship	2524 SHADOW CREEK LN, DES MOINES, IA 50320	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-06	ALDO B. CANCINO HERNANDEZ	aldo94.cansino@gmail.com	DES MOINES	USA	IOWA	JUAN M. MAYORGA	OFELIA BUSTILLOS VALENZUELA	Signed	(1) The employer does not elect the employers’ liability coverage.	ALDO B. CANCINO HERNANDEZ	aldo94.cancino@gmail.com	SELF	DES MOINES	USA	IOWA	JUAN M. MAYORGA	OFELIA BUSTILLOS VALENZUELA	Signed
1723	2023-07-06 11:50	Anonymous (not verified)	94.188.205.175	Doug Ferneding	Proprietorship	21618 270th St. Carroll, IA 51401	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-06	Doug Ferneding	dougferneding@gmail.com	Carroll	Carroll	Iowa	Brenda Klein	Kyle Klein	Signed	(1) The employer does not elect the employers’ liability coverage.	Doug Ferneding	dougferneding@gmail.com	same	Carroll	Carroll	Iowa	Brenda Klein	Kyle Klein	Signed
1722	2023-07-06 10:57	Anonymous (not verified)	94.188.205.169	Brother’s Handyman Services LLC	Proprietorship	1270 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.	2023-07-06	Tyler Dahl	handybros39@gmail.com	Marion, IA	Linn County	Iowa	Jordan Nisiewicz	Charles Woods	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City, MO	Johnson	Missouri	Charles Woods	Jordan Loyd	Signed
1721	2023-07-06 08:19	Anonymous (not verified)	94.188.207.228	Bradford Alexander Carr	Proprietorship	3349 Southgate Ct SW Ste 101	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-06	Bradford Alexander Carr	alex.carr@thrivent.com	Coralville	Johnson	Iowa	Gaylon Heetland	David King	Signed	(1) The employer does not elect the employers’ liability coverage.	Bradford Alexander Carr	alex.carr@thrivent.com	Self	Coralville	Johnson	Iowa	Gaylon Heetland	David King	Signed
1720	2023-07-05 07:19	Anonymous (not verified)	94.188.207.224	Doug FGerneding	Proprietorship	21618 270th St Carroll IA 51401	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-07-05	Doug Ferneding	dougferneding@gmail.com	Carroll	Iowa	Iowa	Jaynie Ferneding	Brenda Klein	Signed	(1) The employer does not elect the employers’ liability coverage.	Doug Ferneding	dougferneding@gmail.com	same	Carroll	Iowa	Iowa	Jaynie Ferneding	Brenda Klein	Signed
1719	2023-07-01 21:34	Anonymous (not verified)	94.188.207.223	Granite & More	Limited Liability Company	4730 Tremont ave 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.	2023-07-01	Hong Le	granite732@yahoo.com	Davenport	Scott	Iowa	Jin Chen	Betty Song	Signed	(1) The employer does not elect the employers’ liability coverage.	Jin Chen	clteam563@gmail.com	Manager	Bettendorf	Scott	Iowa	Jin Chen	Betty Song	Signed
1718	2023-06-29 12:36	Anonymous (not verified)	94.188.205.166	Aidan Obermueller	Proprietorship	2520 N Grandview Avenue, Dubuque, IA 52001	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-27	Aidan Obermueller	aidanobermueller@icloud.com	Dubuque	Dubuque	Iowa	Brenda Lewis	Sue Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Aidan Obermueller	aidanobermueller@icloud.com	self	Dubuque	Dubuque	Iowa	Brenda Lewis	Sue Miler	Signed
1717	2023-06-29 11:42	Anonymous (not verified)	94.188.205.169	POWDER COATING CENTER	Limited Liability Company	61 3RD ST NE HARTLEY IA 51346	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-28	MATT EMBREY	MSEMBREY21@GMAIL.COM	HARTLEY	OBRIEN	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed	(1) The employer does not elect the employers’ liability coverage.	MATT EMBREY	MSEMBREY21@GMAIL.COM	OWNER	HARTLEY	OBRIEN	IOWA	TAMI KLEIN	JENNIFER YOUNGWIRTH	Signed
1716	2023-06-29 09:19	Anonymous (not verified)	94.188.205.169	Christine wanjiru chege	Limited Liability Company	43994 w cowpath rd	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-29	Christine Chege	christine@acuitystaffingagency.com	Maricopa	Pinal	AZ	Daniel Mwangi	Anne Chege	Signed	(1) The employer does not elect the employers’ liability coverage.	Christine chege	christine@acuitystaffingagency.com	Owner	Maricopa	Pinal	AZ	Daniel Mwangi	Anne Chege	Signed
1715	2023-06-28 09:48	Anonymous (not verified)	94.188.207.229	Charles westbrook	Limited Liability Company	2374 31st a Moline	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.	2023-06-28	Charles Micheal westbrook	Westbrook.69.mw@gmail.com	Moline	USA	Illinois	Taylor Davis	N/a	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Charles Micheal Westbrook	Westbrook.69.mw@gmail.com	Gf	Moline	IL	United States	Taylor davis	N/a	Signed
1714	2023-06-27 09:14	Anonymous (not verified)	94.188.205.167	Meier Trucking LLC	Limited Liability Company	35032 308th St, Bellevue, IA 52031	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-14	Brandon Meier	meierturcking87@yahoo.com	Bellevue	Jackson	Iowa	Susan Miller	Nicole Mensen	Signed	(1) The employer does not elect the employers’ liability coverage.	Brandon Meier	meiertrucking87@yahoo.com	self	Bellevue	Jackson	Iowa	Susan Miller	Nicole Mensen	Signed
1713	2023-06-27 09:06	Anonymous (not verified)	94.188.205.175	Ray's Painters, LLC	Limited Liability Company	4120 Mount Alpine Street, Dubuque, IA 52001	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-05-15	Danny Sexton	dsexton766@gmail.com	Dubuque	Dubuque	Iowa	Donna Gotto	Brenda Lewis	Signed	(1) The employer does not elect the employers’ liability coverage.	Ray's Painters LLC	dsexton766@gmail.com	insured	Dubuque	Dubuque	Iowa	Donna Gotto	Brenda Lewis	Signed
1712	2023-06-26 20:33	Anonymous (not verified)	94.188.205.167	Eastern Iowa Overhead Door	Proprietorship	120 N Eliza 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.	2023-06-26	Tim Chapin	easterniadoor@gmail.com	Maquoketa	IA	United States	Carri Lee Waack	Wendy Marie Zaruba	Signed	(1) The employer does not elect the employers’ liability coverage.	Tim Chapin	easterniadoor@gmail.com	Owner	Maquoketa	Jackson	United States	Carri Lee Waack	Wendy Marie Zaruba	Signed
1711	2023-06-26 16:50	Anonymous (not verified)	94.188.207.224	Innovative Behavioral Therapy, LLC	Limited Liability Company	915 Main St. Adel IA 50003	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-26	Ashley Andrew	ashley@innovativebehavioraltherapy.com	Adel	Dallas	Iowa	Thomas Atherton	Brenda Barto	Signed	(1) The employer does not elect the employers’ liability coverage.	Ashley Andrew	ashley@innovativebehavioraltherapy.com	Self	Adel	Dallas	Iowa	Thomas Atherton	Brenda Barto	Signed
1710	2023-06-26 16:10	Anonymous (not verified)	94.188.207.226	Adaptability Plus	Limited Liability Company	904 W 4th St. Waterloo, Iowa 50702	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-26	Timothy Combs	timcombs@afiliowa.org	Waterloo	Iowa	United States	Teresa Tjaden	Mark Moser	Signed	(1) The employer does not elect the employers’ liability coverage.	Mark Moser	mpmmoser@gmail.com	PARTNER	WATERLOO	Black Hawk	Iowa	TERSEA TJADEN	TIM COMBS	Signed
1709	2023-06-26 14:55	Anonymous (not verified)	94.188.205.177	Jeremy Pledge	Proprietorship	3310 East Washington Street, Iowa City, IA 52245	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-26	Jeremy Pledge	worknoplay8@gmail.com	Iowa City, IA	Johnson County	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	Missouri	Charles Woods	Jordan Loyd	Signed
1708	2023-06-25 15:10	Anonymous (not verified)	94.188.207.228	Lopez concrete	Limited Liability Company	2009 otley ave perry Ia 50220	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-25	Erick Lopez	lopez1concrete@gmail.com	Perry	Dallas	IA	Ever tobar.	Elba alejandro	Signed	(1) The employer does not elect the employers’ liability coverage.	Erick lopez	lopez1concreto@gmail.com	Owner	Perry	Dallas	IA	Ever tobar	Elba alejandro	Signed
1707	2023-06-25 10:39	Anonymous (not verified)	94.188.207.224	Michael D Ray	Proprietorship	4944 Holcomb 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.	2023-06-22	Michael D Ray Jr	mdray01@msn.com	Des Moines	Polk	Iowa	Bonnie R Finken	Isaiah O Washington	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael D Ray	mdray01@msn.com	Owner Proprietor	Des Moines	Polk	Iowa	Bonnie R Finken	Isaiah O Washington	Signed
1706	2023-06-23 17:32	Anonymous (not verified)	94.188.205.169	pro plumbing and heating llc	Limited Liability Company	109 w market st, po box 205 saint charles ia 50240	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-23	lee douglas kearney	ankenypro@gmail.com	saint charles	madison	iowa	sheila may kearney	madison grace kearney	Signed	(1) The employer does not elect the employers’ liability coverage.	lee d kearney	ankenypro@gmail.com	owner	saint charles	madison	iowa	sheila may kearney	madison grace kearney	Signed
1705	2023-06-23 16:01	Anonymous (not verified)	94.188.205.176	MV Carpentry LLC	Limited Liability Partnership	32724 U.S. 69 Huxley IA 50124	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-23	Carlos Moreno	Silencitopunk@gmail.com	Huxley	IA	United States	Alejandro Colin	Fermin Luz	Signed	(1) The employer does not elect the employers’ liability coverage.	Carlos Moreno	silencitopunk@gmail.com	Husband	Huxley	IA	United States	Alejandro Colin	Fermin Luz	Signed
1704	2023-06-23 09:00	Anonymous (not verified)	94.188.205.166	THen & Kramer Construcion, Inc.	Partnership	P.O. Box 283 - Epworth, IA 52045	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-22	Dakota Kramer	dparsons@english-insurance.com	Epworth,	Dubuque	IA	Derrick Parsons	Joyce Heims	Signed	(1) The employer does not elect the employers’ liability coverage.	Derrick Parsons	dparsons@english-insurance.com	self	Dyersville	Dubuque	IA	Derrick Parsons	Joyce Heims	Signed
1703	2023-06-23 08:58	Anonymous (not verified)	94.188.205.175	Then & Kramer Construction, Inc	Partnership	P.O. Box 283 - Epworth, IA 52045	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-22	Shannon Kramer	dparsons@english-insurance.com	Epworth	Dubuque	Iowa	Derrick Parsons	Joyce Heims	Signed	(1) The employer does not elect the employers’ liability coverage.	Derrick Parsons	dparsons@english-insurance.com	self	Dyersville	Dubuque	IA	Derrick Parsons	Joyce Heims	Signed
1702	2023-06-22 22:57	Anonymous (not verified)	94.188.207.230	A&M Consulting LLC	Limited Liability Company	1208 5th Ave, North Humboldt Iowa, 50548	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-22	maureen Waweru	maureenrealtyaz@yahoo.com	chandler	AZ	United States	John Waweru	Jessica Bellinger	Signed	(1) The employer does not elect the employers’ liability coverage.	maureen Waweru	maureenrealtyaz@yahoo.com	Self	chandler	AZ	United States	John Waweru	Jessica Bellinger	Signed
1701	2023-06-22 15:03	Anonymous (not verified)	94.188.207.228	Midwest Teleworks	Limited Liability Company	1341 Cachelin Dr Carter Lake IA 51510	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-22	James Trotter	trotterwizard@gmail.com	Carter Lake	Pottawattamie	IA	Shelby Schultz	Elora Trotter	Signed	(1) The employer does not elect the employers’ liability coverage.	James Trotter	trotterwizard@gmail.com	Owner	Carter Lake	Pottawattamie	IA	Shelby Schultz	Elora Trotter	Signed
1700	2023-06-22 14:53	Anonymous (not verified)	94.188.205.166	James Trotter	Limited Liability Company	1341 Cachelin Dr Carter Lake IA 51510	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-22	James Trotter	trotterwizard@gmail.com	Carter Lake	Pottawattamie	IA	Shelby Schultz	Elora Trotter	Signed	(1) The employer does not elect the employers’ liability coverage.	James Trotter	trotterwizard@gmail.com	Self	Carter Lake	Pottawattamie	IA	Shelby Schultz	Elora Trotter	Signed
1699	2023-06-22 07:36	Anonymous (not verified)	94.188.205.175	V2E Advisors LLC	Limited Liability Company	701 Lakeview Ct, Tiffin, IA 52340	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-22	Tyler Rhamy	trhamy@v2eadvisors.com	Tiffin	Iowa	United States	Tasha Rhamy	Tom Rhamy	Signed	(1) The employer does not elect the employers’ liability coverage.	Tyler Rhamy	trhamy@v2eadvisors.com	Member / President	Tiffin	Johnson	Iowa	Tom Rhamy	Tasha Rhamy	Signed
1698	2023-06-20 16:43	Anonymous (not verified)	94.188.205.167	Mike farrell	Proprietorship	306 ne trilein 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.	2023-06-20	Michael David farrell	farrellsfmr@yahoo.com	Ankeny	Polk	Ia	ERICK SCHULST	Kelly Coluzzi	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael David farrell	farrellsfmr@yahoo.com	Owner	Ankeny	Polk	Iowa	Erick Schuldr	Kelly .Coluzzi3	Signed
1697	2023-06-20 14:36	Anonymous (not verified)	94.188.207.225	Quick Logistics LLC	Limited Liability Company	3817 Orleans Avenue, Sioux City, IA 51106	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-20	Tony J Moeller	quick_logistics@outlook.com	Sioux City	IA	United States	Jordan Sitzmann	Cody Stultz	Signed	(1) The employer does not elect the employers’ liability coverage.	Tony J Moeller	quick_logistics@outlook.com	Owner	Sioux City	IA	United States	Jordan Sitzmann	Cody Stultz	Signed
1696	2023-06-19 09:11	Anonymous (not verified)	94.188.205.174	Spruce Cleaning Co	Proprietorship	2302 Cedar Street Granger, Iowa 50109	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-19	Sarah Champion	Sprucecleaningcodsm@gmail.com	Granger	Dallas	Iowa	Amy Greek	Noah Bassett	Signed	(1) The employer does not elect the employers’ liability coverage.	Sarah Champion	Sprucecleaningcodsm@gmail.com	Employer	Granger	Dallas	Iowa	Amy Greek	Noah Bassett	Signed
1695	2023-06-19 06:54	Anonymous (not verified)	94.188.207.224	Leaf Filter	Proprietorship	3060 SE Grimes Blvd Unit 100 Grimes, IA 50111 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.	2023-06-17	Trenton Finch	tjfinch10@gmail.com	Kellogg	Jasper	Iowa	Teagan Kruse	Diane Finch	Signed	(1) The employer does not elect the employers’ liability coverage.	Trenton Finch	tjfinch10@gmail.com	Subcontractor	Kellogg	Jasper	Iowa	Teagan Kruse	Diane Finch	Signed
1694	2023-06-16 14:37	Anonymous (not verified)	94.188.205.176	Leaf Home Solutions LLC	Partnership	3060 SE Grimes Blvd Suite 100-300, Grimes, IA 50111	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-16	Caleb Brincks	chbrincks@gmail.com	628 NE 56th St Ankeny IA, 50021	Polk County	Iowa	Melissa Brincks	Anisha Moten	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	AFTON INC	chbrincks@gmail.com	Owner	Ankeny	Polk	Iowa	Melissa Brincks	Anisha Moten	Signed
1693	2023-06-16 11:37	Anonymous (not verified)	94.188.207.230	Anthony Scroggins	Proprietorship	301 SE 11th Street , Unit 807	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-16	Anthony Scroggins	scroggins710@gmail.com	Grimes	Polk	IA	Cody Wavada	Nate Duden	Signed	(1) The employer does not elect the employers’ liability coverage.	Anthony Scroggins	scroggins710@gmail.com	Self	Grimes	Polk	IA	Cody Wavada	Nate Duden	Signed
1692	2023-06-15 15:20	Anonymous (not verified)	94.188.207.228	Javier Rodriguez	Proprietorship	1512 18th St Des Moines, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-14	Javier A Rodriguez	R.Javier14@gmail.com	Des Moines	Polk	Iowa	Kelly Denger	Debra Stratton	Signed	(1) The employer does not elect the employers’ liability coverage.	Javier A Rodriguez	R.Javier14@gmail.com	self	Des Moines	Polk	Iowa	Kelly Denger	Debra Stratton	Signed
1691	2023-06-14 19:20	Anonymous (not verified)	94.188.205.174	Amazing Painting LLC	Limited Liability Company	1301 Boyd Street, Des Moines, IA 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.	2023-06-14	Evan Michael Regenwether	Evan@amazingpaintingia.com	Des Moines	Polk	Iowa	Austin Matthew Regenwether	Abby Marie Regenwether	Signed	(1) The employer does not elect the employers’ liability coverage.	Evan Michael Regenwether	evan@amaingpaintingia.com	Owner	Des Moines	Polk	Iowa	Austin Matthew Regenwether	Abby Regenwether	Signed
1690	2023-06-13 20:01	Anonymous (not verified)	94.188.207.227	Gerardo Reyes-Lopez	Limited Liability Company	908 West 1st Street, Waterloo, Iowa, 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.	2023-06-13	Gerardo Reyes-lopez	bernardo@reyesconstruct.com	Waterloo	IA	United States	Guillermina Lopez	Bernardo Reyes	Signed	(1) The employer does not elect the employers’ liability coverage.	Denise Seitsinger	denise@harmsinsuranceagency.com	Insurance Agent	Sumner	Bremer	Iowa	Gerardo Reyes	Bernardo Reyes	Signed
1689	2023-06-13 19:55	Anonymous (not verified)	94.188.207.227	Gerardo Reyes-Lopez	Limited Liability Company	908 West 1st Street, 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.	2023-06-13	Gerardo Reyes-lopez	greyeslopez9@gmail.com	Waterloo	Black Hawk	Iowa	Guillermina Lopez	Bernardo Reyes	Signed	(1) The employer does not elect the employers’ liability coverage.	Denise Seitsinger	denise@harmsinsuranceagency.com	Insurance Agent	Sumner	Bremer	Iowa	Gerardo Reyes	Bernardo Reyes	Signed
1688	2023-06-13 09:29	Anonymous (not verified)	94.188.207.228	Ron Burbach	Proprietorship	7760 commerce park Dubuque Iowa 52002	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-13	Ronald V Burbach	allgreenron@msn.com	Dubuque	Dubuqie	Iowa	Mia Burnach	Jerry david	Signed	(1) The employer does not elect the employers’ liability coverage.	Ronald V Burbach	allgreenron@man.com	Same	Dubuque	Dubuque	Iowa	Mia F Burbach	Jerry David	Signed
1687	2023-06-12 16:23	Anonymous (not verified)	94.188.207.229	Jose Manuel Sanchez Loreto	Proprietorship	108 North Hawthorn Drive Altoona, Iowa 50009	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-12	Jose Manual Sanzhez Loreto	jjanna1226@gmail.com	Altoona	Polk	Iowa	Debra Stratton	Kelly Denger	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Manuel Sanchez Loreto	jjana1226@gmail.com	self	Altoona	Polk	Iowa	Debra Stratton	Kelly Denger	Signed

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