580 |
2022-12-09 11:20 |
Anonymous (not verified) |
74.84.79.78 |
Aaron Alley |
101 Teale St. Davis City, IA 50065 |
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. |
2022-01-01 |
Aaron Alley |
alleyre@hotmail.com |
Davis City |
Decatur |
Iowa |
Michael O'Conner |
Ron Rand |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Aaron Alley |
alleyre@hotmail.com |
owner |
Davis City |
Decatur |
Iowa |
Michael O'Conner |
Ron Rand |
Signed |
729 |
2023-08-04 07:39 |
Anonymous (not verified) |
94.188.207.228 |
Barrel Head Winery Inc |
9995 Laudeville Road, Dubuque, IA 52003 |
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. |
2023-08-03 |
Aaron Fuhreck |
sales@barrelheadiowa.com |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Aaron Fuhreck |
sales@barrelheadiowa.com |
Owner |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Derrick Parsons |
Signed |
365 |
2021-11-18 11:48 |
Anonymous (not verified) |
64.5.67.201 |
C & H Body Repair Inc. |
707 Lincoln Ave SE, Orange City, IA 51041 |
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. |
2021-11-12 |
Aaron Huizenga |
ciui@orangecitycomm.net |
Orange City |
Sioux |
Iowa |
Daryl Beltman |
Lori Mars |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Aaron Huizenga |
ciui@orangecitycomm.net |
President |
Orange City |
Sioux |
Iowa |
Daryl Beltman |
Lori Mars |
Signed |
529 |
2022-09-01 13:53 |
Anonymous (not verified) |
72.131.73.148 |
Sozo Companies, Inc. |
23751 Hoover Road, Warren MI 48089 |
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. |
2022-09-01 |
Aaron Rasty |
arasty@sozocompanies.com |
Austin |
Travis |
Texas |
Robert Davis |
Paul Huth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Aaron Rasty |
arasty@sozocompanies.com |
President |
Austin |
Travis |
Texas |
Robert Davis |
Paul Huth |
Signed |
395 |
2022-01-31 15:49 |
Anonymous (not verified) |
75.89.77.218 |
Mind Body Soul 22, Inc. |
101 South St. Delhi, IA 52223 |
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. |
2022-01-31 |
Abby Paige DeGroot |
abby.whittenbaugh@gmail.com |
Delhi |
Deleware |
Iowa |
Kaes Christian DeGroot |
Michael David Whittenbaugh |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Abby Paige DeGroot |
abby@mbs22.com |
President |
Delhi |
Deleware |
Iowa |
Kaes Christian DeGroot |
Michael David Whittenbaugh |
Signed |
978 |
2024-05-08 13:47 |
Anonymous (not verified) |
94.188.205.174 |
Meridian Logistics, LLC |
5249 N Park Pl NE, Unit #2060, Cedar Rapids, IA 52402 |
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. |
2024-05-07 |
Abigail Matthews |
almsolutions2021@gmail.com |
Chicago |
Cook |
IL |
Gayle Matteson |
Jane Calvert |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Abigail Matthews |
almsolutions2021@gmail.com |
Owner |
Chicago |
Cook |
IL |
Gayle Matteson |
Jane Calvert |
Signed |
675 |
2023-05-24 07:55 |
Anonymous (not verified) |
94.188.207.223 |
Sierra Roofing |
401 W 15th Street West Liberty, IA 52776 |
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. |
2023-05-24 |
Abraham Granjeno Sierra |
sierraroofing@gmail.com |
West Liberty |
Muscatine |
Iowa |
Cody Thorpe |
Claudia Venable |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Abraham Granjeno Sierra |
sierraroofing@gmail.com |
Owner/Self |
West Liberty |
Muscatine |
Iowa |
Cody Thorpe |
Claudia Venable |
Signed |
893 |
2024-02-22 10:29 |
Anonymous (not verified) |
94.188.207.226 |
Sierra Roofing |
401 W 15th Street West Liberty, IA 52776 |
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. |
2024-02-22 |
Abraham Granjeno Sierra |
absierra89@gmail.com |
West Liberty |
Muscatine |
Iowa |
Claudia Venable |
Dan Saunders |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Abraham Granjeno Sierra |
absierra89@gmail.com |
Owner/Self |
West Liberty |
Muscatine |
Iowa |
Claudia Venable |
Dan Saunders |
Signed |
826 |
2023-11-22 08:04 |
Anonymous (not verified) |
94.188.207.226 |
Sabuydee Corporation |
617 Davis Ave. / Corning, IA 50841 |
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. |
2023-11-22 |
Adam Grundman |
adamgrundman@gmail.com |
Corning |
Adams |
Iowa |
Carol Penglase |
MIchael Grundman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam Grundman |
adamgrundman@gmail.com |
President |
Corning |
Iowa |
United States |
Carol Penglase |
Michael Grundman |
Signed |
121 |
2020-10-01 09:40 |
Anonymous (not verified) |
50.82.176.77 |
Kinion Towing Inc. |
100 Industrial Park Drive, Clarence, IA 52216 |
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. |
2020-09-30 |
Adam Kinion |
kinionas@yahoo.com |
Tipton |
Cedar |
Iowa |
Michael Blake |
Jeffrey Case |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam Kinion |
kinionas@yahoo.com |
Vice President |
Tipton |
Cedar |
Iowa |
Michael Blake |
Jeffrey Case |
Signed |