933 |
2024-03-22 21:55 |
Anonymous (not verified) |
94.188.205.176 |
Alternative Sport Enterprises |
101 Highway 1 West Iowa City IA 52246 |
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. |
2024-03-22 |
James Michael Pearson |
hatchetjacksiowa@gmail.com |
Savage |
Scott County |
Minnesota |
Payton Kahl |
Trey Kahl |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nick John Carroll |
hatchetjacksiowa@gmail.com |
Owner |
CORALVILLE |
Johnson County |
Iowa |
Payton Kahl |
Trey Kahl |
Signed |
932 |
2024-03-22 21:55 |
Anonymous (not verified) |
94.188.205.175 |
Alternative Sport Enterprises |
101 Highway 1 West Iowa City IA 52246 |
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. |
2024-03-22 |
Nick John Carroll |
hatchetjacksiowa@gmail.com |
CORALVILLE |
Johnson County |
Iowa |
Payton Kahl |
Trey Kahl |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Michael Pearson |
hatchetjacksiowa@gmail.com |
Owner |
Savage |
Scott County |
Minnesota |
Payton Kahl |
Trey Kahl |
Signed |
931 |
2024-03-21 20:54 |
Anonymous (not verified) |
94.188.207.228 |
Cnr drywall llc |
410 w 6th st muscatine Iowa 52761 |
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. |
2024-01-21 |
Jair Romo |
cnrdrywall@gmail.com |
Muscatine |
Muscatine |
Iowa |
Jordy tenorio |
Emmanuel Nunez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cnr drywall |
cnrdrywall@gmail.com |
Owner |
Muscatine |
Muscatine |
Ia |
Jordy tenorio |
Emmanuel Nunez |
Signed |
930 |
2024-03-21 20:44 |
Anonymous (not verified) |
94.188.207.229 |
Southeast Iowa Precision Painting |
714 Lincoln St Ainsworth IA 52201 |
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. |
2024-03-21 |
Kirby Jay Shetler |
kirbyshetler@gmail.com |
Ainsworth |
Washington |
Iowa |
Kirby Shetler |
Demi Shetler |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Southeast Iowa Precision Painting |
kirbyshetler@gmail.com |
Owner |
Ainsworth |
Washington |
Iowa |
Kirby Shetler |
Demi Shetler |
Signed |
929 |
2024-03-21 19:00 |
Anonymous (not verified) |
94.188.205.167 |
Stewart and Belzer Construction |
1103 n 8th Ave |
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. |
2024-03-21 |
Logan belzer |
lbelzer1999@gmail.com |
Washington |
Washington |
Iowa |
Joseph Stewart |
Graham Hagge |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Logan belzer |
lbelzer1999@gmail.com |
Owner |
Washington |
Washington |
Iowa |
Joseph Stewart |
Graham Hagge |
Signed |
928 |
2024-03-21 16:20 |
Anonymous (not verified) |
94.188.207.230 |
Midwest Premier Painting |
5496 Hunt Rd, Burlington IA 52601 |
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. |
2024-03-21 |
Christopher West |
cswest1974@yahoo.com |
Burlington |
Des Moines |
IA |
Amy West |
McKenzie West |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christopher West |
cswest1974@yahoo.com |
Owner |
Burlington |
Des Moines |
IA |
Amy Wets |
McKenzie West |
Signed |
927 |
2024-03-20 23:27 |
Anonymous (not verified) |
94.188.205.177 |
RRB, LLC |
4444 1st Ave NE Ste 510 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. |
2023-03-20 |
Kelli Holton |
kelli@rebelroseboutique.co |
Coralville |
IA |
United States |
Dave Booth |
Ann Holton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kelli Holton |
kelli@rebelroseboutique.co |
Owner |
Coralville |
IA |
United States |
Dave Booth |
Ann Holton |
Signed |
926 |
2024-03-20 15:25 |
Anonymous (not verified) |
94.188.207.230 |
CML Constuction LLC |
2116 Park Ave Muscatine, Iowa 52761 |
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. |
2024-03-20 |
CHRIS LINNENKAMP |
cmlconstructionllc@gmail.com |
Muscatine |
IA |
IA |
Gabriel Diaz |
Byron Lopez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CHRIS LINNENKAMP |
cmlconstructionllc@gmail.com |
Owner |
Muscatine |
IA |
IA |
Gabriel Diaz |
Byron Lopez |
Signed |
925 |
2024-03-20 14:08 |
Anonymous (not verified) |
94.188.207.225 |
Magels concrete cutting and drilling services inc |
13554 124th ave Burlington iowa 52601 |
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. |
2023-04-01 |
Trent magel |
tmagel123@gmail.com |
Burlington |
Des moines |
Iowa |
Tamara crawford |
Joseph Messer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Trent magel |
tmagel123@gmail.com |
Owner |
Burlington |
Des moines |
Iowa |
Tamara crawford |
Justice christensen |
Signed |
924 |
2024-03-19 16:40 |
Anonymous (not verified) |
94.188.207.228 |
Brite-Way Services Inc. |
621 Morningside Dr., Burlington IA 52601 |
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. |
2024-03-19 |
Richard Luckenbill |
britewayburl@gmail.com |
Burlington |
Iowa |
Iowa |
Tammy Luckenbill |
Brooke Mathiasmeier |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Richard Luckenbill |
britewayburl@gmail.com |
Owner, President |
Burlington |
Iowa |
Iowa |
Tammy Luckenbill |
Brooke Mathiasmeier |
Signed |