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Rejection of Workers' Compensation or Employers' Liability Coverage

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# Submitted User IP address Name of Corporation: Address of Corporation Home Office: Statement 1 Agreement: Statement 2 Agreement: Statement 3 Agreement: Statement Agreement: Check Either Alternative (1) or (2): Date: Full Name of Individual: Email: City of Residence: County of Residence: State of Residence: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Agreement: Alternative Selection: Full Name of Authorized Agent: Email of Authorized Agent: Relationship to Corporation of Authorized Agent: City of Residence: County of Residence: State: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Indication:
43 2020-02-28 09:50 Anonymous (not verified) 173.24.140.77 W R Main Contractor Inc 1620 NW 78th Street, Clive, IA 50325 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. 2020-02-28 Cindy Jo Ohmart co4mainco@aol.com West Des Moines Polk Iowa Jill Ann Reber Alane Marguerite Richardson Signed (1) The corporation rejects the employers’ liability coverage. Mark I Main markmain@icloud.com President Waukee Dallas Iowa Jill Ann Reber Alane Marguerite Richardson Signed
42 2020-02-16 19:13 Anonymous (not verified) 207.199.193.217 S J Hernandez, Inc 19738 133rd Street Bloomfield, IA 52537 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. 2020-02-16 Salvador Hernandez-Perez jessieatcjs@gmail.com Bloomfield Davis Iowa Jessica Hernandez Joseph Olinger Signed (1) The corporation rejects the employers’ liability coverage. Salvador Hernandez-Perez jessieatcjs@gmail.com Owner Bloomfield Davis Iowa Jessica Hernandez Joseph Olinger Signed
41 2020-02-16 19:09 Anonymous (not verified) 207.199.193.217 S J Hernandez, Inc 19738 133rd Street Bloomfield, IA 52537 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. 2020-02-16 Jessica Hernandez jessieatcjs@gmail.com Bloomfield Davis Iowa Salvador Hernandez-Perez Joseph Olinger Signed (1) The corporation rejects the employers’ liability coverage. Jessica Hernandez jessieatcjs@gmail.com Owner Bloomfield Davis Iowa Salvador Hernandez-Perez Joseph Olinger Signed
40 2020-02-14 09:22 Anonymous (not verified) 50.83.38.221 Pa's Construction LLC 2350 Glass RD NE 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. 2020-02-14 Daniel Saunders dan2112411@yahoo.com Cedar Rapids USA_IA USA_IA Walt Cheney Becky Cheney Signed (1) The corporation rejects the employers’ liability coverage. Daniel Saunders dan2112411@yahoo.com Owner- Manager Cedar Rapids USA_IA USA_IA Walt Cheney Becky Cheney Signed
39 2020-02-10 16:37 Anonymous (not verified) 67.212.103.193 Voelker Property Management, LLC 1705 Quail Run Lane, Cedar Falls, 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. 2020-02-10 Craig D Voelker cvoelker@cfu.net Cedar Falls Black Hawk Iowa Craig DVoelker Nikki D Voelker Signed (1) The corporation rejects the employers’ liability coverage. Craig D Voelker cvoelker@cfu.net Owner Cedar Falls Black Hawk Iowa Craig D Voelker Nikki D Voelker Signed
38 2020-02-08 13:16 Anonymous (not verified) 208.126.52.97 Savage Industries Inc 2368 110th street Delmar, ia 52037 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. 2020-02-08 Jordan Hicks jjjhicks22@gmail.com Delmar Clinton Iowa Brittany Hicks Alex Laban Signed (1) The corporation rejects the employers’ liability coverage. Jordan Hicks jjjhicks22@gmail.com President Delmar Clinton Iowa Brittany Hicks Alex Laban Signed
37 2020-02-06 15:49 Anonymous (not verified) 100.42.95.100 Matthew Saboe 2075 330th St, Spencer IA 51301 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. 2020-02-06 Matthew Saboe galmgirl@gmail.com Spencer Clay IA Laura Ashley Tauscher Diane Kimball Signed (1) The corporation rejects the employers’ liability coverage. Matthew Saboe galmgirl@gmail.com Owner Spencer Clay IA Laura Ashley Tauscher Diane Kimball Signed
36 2020-01-31 14:59 Anonymous (not verified) 96.31.22.239 HOGMILE PORK LLC 2032 220TH ST INWOOD IOWA 51240 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. 2020-01-31 GLENN VANDEVEGTE glenvv@alliancecom.net INWOOD LYON IOWA LISA FABER ERIC TEGROOTENHUIS Signed (1) The corporation rejects the employers’ liability coverage. GLENN VANDEVEGTE glennvv@alliancecom.net self INWOOD LYON IOWA LISA FABER ERIC TEGROOTENHUIS Signed
35 2020-01-31 14:56 Anonymous (not verified) 96.31.22.239 HOGMILE PORK LLC 2032 220TH ST INWOOD, IOWA 51240 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. 2020-01-31 GALEN VANDEVEGTE galenvv@alliancecom.net INWOOD LYON IOWA LISA FABER ERIC TEGROOTENHUIS Signed (1) The corporation rejects the employers’ liability coverage. GALEN VANDEVEGTE galenvv@alliancecom.net SELF INWOOD LYON IOWA LISA FABER ERIC TEGROOTENHUIS Signed
34 2020-01-16 13:10 Anonymous (not verified) 108.171.132.188 B & C Lawn Care Inc P.O. Box 55, Boone, IA 50036 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. 2020-01-01 Caleb Elliott onethird4599@gmail.com Boone Boone Iowa Katie Frame Jessica Carroll Signed (1) The corporation rejects the employers’ liability coverage. Caleb Elliott onethird4599@gmail.com Owner Boone Boone IOWA Katie Frame Jessica Carroll Signed