Submission #25

Submission information
Submitted by Anonymous (not verified)
Thu, 2020-01-02 09:17
207.191.194.182
Information about Corporation
Waukee CabinetWorks LLC
70 SE Laurel St, Waukee IA 50263
Agreements by Individual
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.
I understand that my rejection 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 my employment with the corporation.
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation.
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation.
(1) I reject the employers’ liability coverage.
Individual Information
Mon, 2019-12-23
Jason Balm
Waukee
Dallas
Iowa
Chris Andrews
Dave Creighton Sr
Signed

By selecting the button labeled "Signed", I hereby sign this form and, in doing so, swear or affirm that:

  1. The information I have provided is true and correct to the best of my knowledge.
  2. I am the president, vice president, secretary, or treasurer of the corporation.
  3. I am one of not more than four corporate officers rejecting coverage.
  4. I am signing this form in front of the two witnesses I have identified.
  5. Both of the witnesses are disinterested individuals who are not, formally or informally, affiliated with the corporation.
  6. I understand that this form is a public record open to public inspection under Iowa Code chapter 22 and section 87.22.
Agreement by Corporation.
(1) The corporation rejects the employers’ liability coverage.
Corporation Information
Chris Rappe
Operations Manager
Waukee
Dallas
Iowa
Chris Andrews
Dave Creighton SR
Signed

By selecting the button labeled "Signed", I hereby sign this form and swear or affirm that:

  1.     The information I have provided is true and correct to the best of my knowledge.
  2.     I am authorized to reject or decline to reject employers’ liability coverage on behalf of the corporation.
  3.     I am signing this form in front of the two witnesses I have identified.
  4.     Both of the witnesses are disinterested individuals who are not, formally or informally, affiliated with the corporation.
  5.     I understand that this form is a public record open to public inspection under Iowa Code chapter 22 and section 87.22.