345 |
2021-10-11 15:36 |
Anonymous (not verified) |
173.188.10.36 |
Outdoor Pros LLC |
4525 HWY 22 SE |
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. |
2021-10-11 |
Erik Scott Alberhasky |
erikalberhas@gmail.com |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik Scott Alberhasky |
erikalberhas@gmail.com |
Owner |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
896 |
2024-02-23 16:14 |
Anonymous (not verified) |
94.188.205.167 |
Convenience Stores Business Inc |
1615 Bishop Ave, Waterloo, IA 50707 |
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. |
2025-02-26 |
John Sarwar |
trampride@aol.com |
Waterloo |
Black Hawk |
IA |
. |
. |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jason Koch |
jason_koch@veridiancu.org |
Agent |
Waterloo |
Black Hawk |
IA |
. |
. |
Signed |
605 |
2023-02-17 11:29 |
Anonymous (not verified) |
94.188.207.223 |
McDonald Construction |
617 Kingsley Ave, Waterloo Iowa |
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. |
2022-02-17 |
Todd Gelner |
toddandabbey@yahoo.com |
Denver |
Bremer |
Iowa |
Abbey Gelner |
Abbey Elizabeth-Anne Gelner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Todd Gelner |
toddandabbey@yahoo.com |
Self |
Denver |
Bremer |
Iowa |
Abbey Gelner |
Karen Henry |
Signed |
462 |
2022-05-02 16:01 |
Anonymous (not verified) |
71.39.227.238 |
IN SEASON LAWN CARE LLC |
32841 HOMESTEAD DR, GRANGER, IA 50109 |
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. |
2022-05-02 |
JOSEPH CRAIG COVER |
inseason98@gmail.com |
Granger |
Dallas |
Iowa |
Abbey Luellen |
Steve Phillips |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph Craig Cover |
inseason98@gmail.com |
Owner |
Granger |
Dallas |
Iowa |
Abbey Luellen |
Steve Phillips |
Signed |
463 |
2022-05-02 16:02 |
Anonymous (not verified) |
71.39.227.238 |
IN SEASON LAWN CARE LLC |
32841 HOMESTEAD DR, GRANGER, IA 50109 |
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. |
2022-05-02 |
CHEYENNE COVER |
inseason98@gmail.com |
Granger |
Dallas |
Iowa |
Abbey Luellen |
Steve Phillips |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CHEYENNE Cover |
inseason98@gmail.com |
Owner |
Granger |
Dallas |
Iowa |
Abbey Luellen |
Steve Phillips |
Signed |
985 |
2024-05-13 17:15 |
Anonymous (not verified) |
94.188.207.225 |
Rail and Road Equipment Co |
1797 G50 HWY. St. Charles, IA. 50240 |
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. |
2024-05-13 |
Jeffrey Pontier |
railandroad@myomnotel.com |
St Charles |
Warren |
IA |
Abbi Goering |
Travis Allen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffrey Pontier |
railandroad@myomnitel.com |
President |
St Charles |
Warren |
IA |
Abbi Goering |
Travis Allen |
Signed |
986 |
2024-05-13 17:26 |
Anonymous (not verified) |
94.188.207.229 |
Rail and Road Equipment Co |
1797 G50 HWY. St. Charles, IA. 50240 |
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. |
2024-05-13 |
Ranae Pontier |
railandroad@myomnitel.com |
St Charles |
Warren |
IA |
Abbi Goering |
Travis Allen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ranae Pontier |
railandroad@myomnitel.com |
Vice President |
St Charles |
Warren |
IA |
Abbi Goering |
Travis Allen |
Signed |
224 |
2021-03-29 11:26 |
Anonymous (not verified) |
174.198.71.64 |
Pro wash Dubuque inc |
1795 Atlantic st |
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. |
2021-03-28 |
Jordan John block |
prowashdubuque@gmail.com |
East Dubuque |
Jo Davis |
IL |
Abigail Ann Metcalf |
Dawn Marie block |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ludovissy insurance |
jeff@ludovissyandassociates.com |
He is my agent |
Dubuque |
Dubuque country |
IA |
Jordan John block |
Abigail Ann Metcalf |
Signed |
421 |
2022-03-07 17:14 |
Anonymous (not verified) |
174.215.244.140 |
MJ Kunkel Trucking, LLC |
403 N Ash St |
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. |
2022-03-07 |
Michael John Kunkel |
mjkunkeltrucks@gmail.com |
Marcus |
IA |
United States |
Adam Bartels |
Karlee Ohrt |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael John Kunkel |
mikekunkel0361@gmail.com |
Self |
Marcus |
IA |
United States |
Adam Bartels |
Karlee Ohrt |
Signed |
804 |
2023-10-31 13:04 |
Anonymous (not verified) |
94.188.207.226 |
NeX Level Restoration LLC |
314 8th ST NW, Cedar Rapids, IA 52405 |
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. |
2023-10-31 |
Bobby Caldwell SR |
blc5000@msn.com |
Cedar Rapids |
Linn |
IA |
Adam Feldmann |
Tarin Tanner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bobby Caldwell |
blc5000@msn.com |
Self |
Cedar Rapids |
Linn |
IA |
Adam Feldmann |
Tarin Tanner |
Signed |