853 |
2024-01-16 13:21 |
Anonymous (not verified) |
94.188.207.230 |
NeX Level Moving |
5634 Deerwood St SW Cedar Rapids, IA 52404 United States |
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. |
2024-01-16 |
Hayden Schaefer Wagner |
24haywag24@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Stephanie Allegra Wagner |
Hayden Schaefer Wagner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Hayden Schaefer Wagner |
24haywag24@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Hayden Schaefer Wagner |
Stephanie Allegra Wagner |
Signed |
267 |
2021-05-24 11:25 |
Anonymous (not verified) |
70.168.33.178 |
Town and Country Aqua Club |
22687 James Dr, council bluffs, IA 51503 |
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. |
2021-05-24 |
Cheri Smith |
3smithathome@cox.net |
Council Bluffs |
Pottawattamie |
IA |
Mark Smith |
Kirstyn Smith |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cheri Smith |
3smithathome@cox.net |
Secretary |
Council Bluffs |
Pottawattamie |
IA |
Mark Smith |
Kirstyn Smith |
Signed |
616 |
2023-03-02 13:32 |
Anonymous (not verified) |
94.188.207.229 |
Kevin Pritchard |
126 S Main St, Dundee IA 52038 |
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. |
2023-03-02 |
Kevin Pritchard |
486@gmail.com |
Dundee |
Delaware |
Iowa |
Mitzi Hoeger |
Roger Gibbs |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kevin Pritchard |
486@gmail.com |
Self |
Dundee |
Delaware |
Iowa |
Mitzi Hoeger |
Roger Gibbs |
Signed |
366 |
2021-11-23 12:20 |
Anonymous (not verified) |
173.19.234.191 |
Brezina Homes, Inc |
9008 NW 73rd Place, Johnston, IA 50131 |
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. |
2021-11-23 |
Allen J. Brezina |
a.brezina@mchsi.com |
Johnston |
Polk |
Iowa |
Christopher Winterboer |
Melissa Winterboer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Allen J. Brezina |
a.brezina@mchsi.com |
President |
Johnston |
Polk |
Iowa |
Christopher Winterboer |
Melissa Winterboer |
Signed |
367 |
2021-11-23 12:23 |
Anonymous (not verified) |
173.19.234.191 |
Brezina Homes, Inc |
9008 NW 73rd Place, Johnston, IA 50131 |
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. |
2021-11-23 |
Monica M. Brezina |
a.brezina@mchsi.com |
Johnston |
Polk |
Iowa |
Christopher Winterboer |
Melissa Winterboer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Allen J. Brezina |
a.brezina@mchsi.com |
President |
Johnston |
Polk |
Iowa |
Christopher Winterboer |
Melissa Winterboer |
Signed |
369 |
2021-11-30 09:37 |
Anonymous (not verified) |
173.19.234.191 |
Brezina Homes, Inc |
9008 NW 73rd Place, Johnston, IA 50131 |
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. |
2021-11-30 |
Anthony L. Brezina |
Tony.brezina@cbdsm.com |
West Des Moines |
Dallas |
Iowa |
Christopher Winterboer |
Melissa Winterboer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Allen J. Brezina |
a.brezina@mchsi.com |
President |
Johnston |
Polk |
Iowa |
Christopher Winterboer |
Melissa Winterboer |
Signed |
382 |
2022-01-05 14:05 |
Anonymous (not verified) |
173.19.234.191 |
Brezina Homes, Inc |
9008 NW 73rd Place, Johnston, IA 50131 |
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. |
2022-01-05 |
Jennifer Brezina |
Jenniferfisher71979@gmail.com |
West Des Moines |
Dallas |
Iowa |
Christopher Winterboer |
Melissa Winterboer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Allen J. Brezina |
a.brezina@mchsi.com |
President |
Johnston |
Polk |
Iowa |
Christopher Winterboer |
Melissa Winterboer |
Signed |
949 |
2024-04-05 20:16 |
Anonymous (not verified) |
94.188.207.223 |
Viramontes Quality Lawncare LLC. |
3029 E Washington Ave Des Moines,Iowa 50317 |
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. |
2023-04-05 |
Andres Viramontes Barron |
a.viramontes1989@gmail.com |
Des Moines |
Iowa |
United States |
Clayton Garrison |
Gloria Cardenas |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andres Viramontes |
a.viramontes1989@gmail.com |
owner |
Des Moines |
Iowa |
United States |
Clayton Garrison |
Gloria Cardenas |
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 |
816 |
2023-11-15 15:22 |
Anonymous (not verified) |
94.188.205.166 |
MO VALLEY TACO INC |
1971 LINCOLN HWY MISSOURI VALLEY IA 51555 |
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. |
2023-11-01 |
MARTIN ALVAREZ |
abelardosmexicanfresh7@gmail.com |
MISSOURI VALLEY |
HARRISON |
IA |
GONZALO MUNOZ |
SILVIA CHAVEZ |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
MARTIN ALVAREZ |
abelardosmexicanfresh7@gmail.com |
OWNER |
MISSOURI VALLEY |
HARRISON |
IA |
GONZALO MUNOZ |
SILVIA CHAVEZ |
Signed |