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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:
114 2020-09-04 13:11 Anonymous (not verified) 107.182.207.0 KEITH N SLYTER PO 2632 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. 2020-09-04 KEITH N SLYTER KNSCONST@GMAIL.COM DAVENPORT 25|IA iowa KEITH N SLYTER KEITH N SLYTER Signed (1) The corporation rejects the employers’ liability coverage. KEITH N SLYTER KNSCONST@GMAIL.COM owner DAVENPORT 25|IA iowa KEITH N SLYTER KEITH N SLYTER Signed
55 2020-04-06 16:25 Anonymous (not verified) 74.221.44.37 Steele Land & Livestock, Inc 1040 190th St, Anita, IA 50020 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. 2020-04-06 Doug Steele dsteele@midlands.net Anita Adair Iowa Sheryl Leonard Cheryl Ellis Signed (1) The corporation rejects the employers’ liability coverage. Doug Steele dsteele@midlands.net President Anita Adair Iowa Sheryl Leonard Cheryl Ellis Signed
107 2020-08-04 13:42 Anonymous (not verified) 97.64.131.90 BNR Construction INC 210 4th St Orient, IA 50858 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. 2020-08-04 Bennie Shinn bnrconstllc@gmail.com Orient Adair Iowa Chris Lane Thomas Hartsock Signed (1) The corporation rejects the employers’ liability coverage. Bennie Shinn bnrconstllc@gmail.com President Orient Adair Iowa Chris Lane Thomas Hartsock Signed
111 2020-08-25 14:37 Anonymous (not verified) 204.155.61.217 BNR Construction INC 210 4th St Orient,Ia 50858 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. 2020-07-15 Bennie Shinn bnrconstructllc@gmail.com Orient Adair Iowa Chris Lane Thomas Hartsock Signed (1) The corporation rejects the employers’ liability coverage. Bennie Shinn bnrconstructllc@gmail.com President Orient Adair Iowa Chris Lane Thomas Hartsock Signed
112 2020-08-26 10:18 Anonymous (not verified) 97.64.131.90 BNR Construction INC 210 4th St Orient, IA 50858 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. 2020-07-15 Bennie Shinn bnrconstllc@gmail.com Orient Adair Iowa Chris Lane Thomas Hartsock Signed (1) The corporation rejects the employers’ liability coverage. Bennie Shinn bnrconstllc@gmail.com President Orient Adair Iowa Chris Lane Thomas Hartsock Signed
870 2024-01-26 07:57 Anonymous (not verified) 94.188.207.228 Kodiak Group Security LLC 1978 NW 92nd CT STE 2 Clive, Iowa 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. 2024-01-23 Howard Alton Johnston Jr howard@kodiakgroup.org Stuart Adair IA Joseph Crawford Howard Williams Signed (1) The corporation rejects the employers’ liability coverage. Howard Alton Johnston Jr howard@kodiakgroup.org Owner Stuart Adair Iowa Jospeh Crawford Howard Williams Signed
981 2024-05-10 15:31 Anonymous (not verified) 94.188.205.168 Jacob Thompson DBA Jake Thompson Trucking 2524 Delta Ave, Bridgewater, IA 50837 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. 2024-05-10 Jake Thompson jakethompsontrucking@yahoo.com Bridgewater Adair Iowa Daniela Scacchi Jeff Thompson Signed (1) The corporation rejects the employers’ liability coverage. Jake Thompson jakethompsontrucking@yahoo.com Self Bridgerwater Adair IA Daniela Scacchi Jeff Thompson Signed
825 2023-11-22 08:02 Anonymous (not verified) 94.188.207.224 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 Nantawan Grundman lakejournal@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
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
87 2020-06-09 14:49 Anonymous (not verified) 185.169.109.170 Sweeney Builders Inc 511 8th Ave NW 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. 2020-06-09 Michael Lee Sweeney mike@sweeneybuilders.com Waukon Allamakee Iowa Shawna Sweeney Jean Gavin Signed (1) The corporation rejects the employers’ liability coverage. Shawna Sweeney shawna@sweeneybuilders.com Vice President Waukon Allamakee IA Mike Sweeney Jean Gavin Signed
349 2021-10-22 11:08 Anonymous (not verified) 63.152.48.235 Strong Rock and Gravel LLC 721 S Front St, Lansing, IA 52151 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. 2021-09-04 Ronald Strong stronggravel@gmail.com Llansing Allamakee Iowa James H Bieber Jane Tepesch Signed (1) The corporation rejects the employers’ liability coverage. James H Bieber biebinre@qwestoffice.net Insurance Agent WAUKON Allamakee Iowa James H Bieber Jane Tepesch Signed
403 2022-02-09 14:14 Anonymous (not verified) 108.59.100.21 T Js Fencing Inc 461 Hwy 76, Harpers Ferry IA 52146 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. 2022-01-13 Travis Johanningmeier tjfence@acegroup.cc Harpers Ferry Allamakee Iowa Jessica Kruse Jane M Regan Signed (1) The corporation rejects the employers’ liability coverage. Travis Johanningmeier tjfence@acegroup.cc President Harpers Ferry Allamakee Iowa Jessica Kruse Jane M Regan Signed
763 2023-09-05 12:31 Anonymous (not verified) 94.188.205.168 Blue Ridge Enterprises, LLC 604 old sixteen road Waterville, IA 52170 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. 2023-09-05 Nathan Eldon Leas nleas69@gmail.com Waterville Allamakee Iowa Mark Wright Gary Mahr Signed (1) The corporation rejects the employers’ liability coverage. Nathan Eldon Leas nleas69@gmail.com President/owner Waterville Allamakee Iowa Mark Wright Gary Mahr Signed
666 2023-05-05 16:20 Anonymous (not verified) 94.188.205.177 Furever Friends Rescue of Appanoose, Inc PO Box 663, Centerville, Iowa 52544 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. 2023-05-05 Michael Miller mrmillerfb@gmail.com Centerville Appanoose Iowa Kimberly Stonehouse Jennifer Appler Signed (1) The corporation rejects the employers’ liability coverage. Michael Miller mrmillerfb@gmail.com Secretary Centerville Appanoose Iowa Kimberly Stonehouse Jennifer Appler Signed
725 2023-08-02 17:25 Anonymous (not verified) 94.188.207.225 Furever Friends Rescue of Appanoose, Inc 19507 Hwy 2, Centerville, Iowa 52544 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. 2023-08-02 Dustin Cain Bozwell dcbozwell@gmail.com Centerville Appanoose Iowa Kimberly Stonehouse Jennifer Appler Signed (1) The corporation rejects the employers’ liability coverage. Dustin Bozwell dcbozwell@gmail.com President Centerville Appanoose Iowa Kimberly Stonehouse Jennifer Appler Signed
726 2023-08-02 17:30 Anonymous (not verified) 94.188.205.169 Furever Friends of Appanoose, Inc 19507 Hwy 2, Centerville, Iowa 52544 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. 2023-08-02 Clint Raymond Housh clinthoush@lockridgeinc.com Centerville Appanoose Iowa Brian Seeman Drew Power Signed (1) The corporation rejects the employers’ liability coverage. Clint Housh clinthoush@lockridgeinc.com Vice President Centerville Appanoose Iowa Brian Seeman Drew Power Signed
727 2023-08-02 18:25 Anonymous (not verified) 94.188.205.176 Furever Friends Rescue of Appanoose, Inc 19507 Hwy 2, Centerville, Iowa 52544 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. 2023-08-02 Krystal Fowler krystalfowler@gmail.com Cincinnati Appanoose Iowa Jennifer Appler Kimberly Stonehouse Signed (1) The corporation rejects the employers’ liability coverage. Krystal Fowler krystalfowler@gmail.com Treasurer Cincinnati Appanoose Iowa Jennifer Appler Kim Stonehouse Signed
758 2023-08-29 11:56 Anonymous (not verified) 94.188.207.229 Ellison building and repair 2722 645th moravia IA 52571 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. 2023-08-18 Keeton Ellison keeton2005@gmail.com Moravia Appanoose Iowa Cory Ellison Sammy Ellison Signed (1) The corporation rejects the employers’ liability coverage. Sammy Ellison sammyllsn@yahoo.com Mom Moravia Monroe Iowa Cory Ellison Sammy Ellison Signed
708 2023-07-14 09:24 Anonymous (not verified) 94.188.205.166 Ellis Flying Service Inc. 6550 HWY 17 South Newport AR 72112 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. 2023-07-14 Mark Ellis fly@ellisflying.com Newport Arkansas United States Alex Webb Becky Ellis Signed (1) The corporation rejects the employers’ liability coverage. Mark A Ellis fly@ellisflying.com President Newport Arkansas United States Alex Webb Becky Ellis Signed
433 2022-03-27 15:30 Anonymous (not verified) 208.126.206.146 J B Engraving 206 4th street East Newhall , Iowa 52315 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. 2022-03-27 John Lauterwasser engravingjb@gmail.com Newhall Benton Iowa Lisa Jane Meeks Brandon Lauterwasser Signed (1) The corporation rejects the employers’ liability coverage. LC Anderson lbandins@southslope.net N/A Newhall Benton Iowa Lisa Jane Meeks Brandon Lauterwasser Signed
434 2022-03-27 15:30 Anonymous (not verified) 208.126.206.146 J B Engraving 206 4th street East Newhall , Iowa 52315 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. 2022-03-27 John Lauterwasser engravingjb@gmail.com Newhall Benton Iowa Lisa Jane Meeks Brandon Lauterwasser Signed (1) The corporation rejects the employers’ liability coverage. LC Anderson lbandins@southslope.net N/A Newhall Benton Iowa Lisa Jane Meeks Brandon Lauterwasser Signed
445 2022-04-14 15:52 Anonymous (not verified) 72.10.21.42 Babcock Services Idaho, Inc. 8113 W QUINAULT AVENUE 201, Kennewick, WA 99336 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. 2022-04-14 Keith Myers CCLYDE@BABCOCKSERVICES.COM KENNEWICK Benton Washington Linda McAlister Cesar Jimenez Signed (1) The corporation rejects the employers’ liability coverage. CARMEN CLYDE CCLYDE@BABCOCKSERVICES.COM Secretary KENNEWICK Benton Washington Linda McAlister Cesar Jimenez Signed
446 2022-04-14 15:54 Anonymous (not verified) 72.10.21.42 Babcock Services Idaho, Inc. 8113 W QUINAULT AVENUE 201, Kennewick, WA 99336 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. 2022-04-14 Phil Gallagher pgallagher@babcockservices.com Richland Benton Washington Linda McAlister Cesar Jimenez Signed (1) The corporation rejects the employers’ liability coverage. CARMEN CLYDE CCLYDE@BABCOCKSERVICES.COM Secretary KENNEWICK Benton Washington Linda McAlister Cesar Jimenez Signed
497 2022-06-16 11:09 Anonymous (not verified) 72.10.21.42 Babcock Services Idaho, Inc. 8113 W QUINAULT AVENUE 201, KENNEWICK, WA 99336 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. 2022-06-01 WALLACE KENNEDY wkennedy@babcockservices.com Richland Benton Washington Angie Jimenez Karen Patterson Signed (1) The corporation rejects the employers’ liability coverage. Carmen Clyde cclyde@babcockservices.com Secretary Kennewick Benton Washington Angie Jimenez Karen Patterson Signed
534 2022-09-09 08:35 Anonymous (not verified) 192.95.125.128 Darri, Inc. 903 W 4th Street, Vinton, IA 52349 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. 2022-09-09 Teri Jo Sellers teri@bobbinsandboards.com Vinton Benton Iowa Hanna Gregory Jennie Lynn Roster Signed (1) The corporation rejects the employers’ liability coverage. Darran Kenneth Sellers darran.sellers@mrhandyman.com President Vinton Benton Iowa Hanna Gregory Jennie Lynn Roster Signed
914 2024-03-08 09:02 Anonymous (not verified) 94.188.205.167 Lubbock Construction Inc 3035 66 St Shellsburg IA 52332 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. 2024-03-08 Justin L Lubbock justinlubbock@yahoo.com Shellsburg Benton IA Cherie Lynn Scott Jodie Marie Little Signed (1) The corporation rejects the employers’ liability coverage. Justin L Lubbock justinlubbock@yahoo.com President Shellsburg Benton IA Cherie Lynn Scott Jodie Marie Little 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
106 2020-07-27 12:12 Anonymous (not verified) 206.125.132.254 Pacos Roofing Inc 837 Lynkaylee Dr Waterloo, IA 50701 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. 2020-07-27 Blanca Garcia Pacosroofing@outlook.com Waterloo Black Hawk Iowa Kaitlin Schepers Sarah Whalen Signed (1) The corporation rejects the employers’ liability coverage. Blanca Garcia Pacosroofing@outlook.com Owner Waterloo Black Hawk Iowa Kaitlin Schepers Sarah Whalen Signed
358 2021-11-15 09:39 Anonymous (not verified) 165.225.57.41 Jerry Steward Trucking Inc. 319 W. 7th Street, Janesville, IA 50647 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. 2021-10-22 Jerry Steward Sr. cedarfalls.oil@gmail.com Cedar Falls Black Hawk Iowa Meredith Morrow Susan Fiser Signed (1) The corporation rejects the employers’ liability coverage. Jerry Steward Jr. cedarfalls.oil@gmail.com Vice-President Cedar Falls Black Hawk Iowa Meredith Morrow Susan Fiser Signed
359 2021-11-15 09:43 Anonymous (not verified) 165.225.57.41 Jerry Steward Trucking Inc 319 W. 7th Street, Janesville, IA 50647 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. 2021-10-22 Jerry Steward Jr. cedarfalls.oil@gmail.com Cedar Falls Black Hawk Iowa Meredith Morrow Susan Fiser Signed (1) The corporation rejects the employers’ liability coverage. Jerry Steward Sr. cedarfalls.oil@gmail.com President Cedar Falls Black Hawk Iowa Meredith Morrow Susan Fiser Signed
360 2021-11-15 09:47 Anonymous (not verified) 165.225.57.41 Jerry Steward Trucking Inc 319 W. 7th Street, Janesville, IA 50647 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. 2021-10-22 Ruth Steward cedarfalls.oil@gmail.com Cedar Falls Black Hawk Iowa Meredith Morrow Susan Fiser Signed (1) The corporation rejects the employers’ liability coverage. Jerry Steward Sr. cedarfalls.oil@gmail.com President Cedar Falls Black Hawk Iowa Meredith Morrow Susan Fiser Signed
511 2022-07-15 11:41 Anonymous (not verified) 50.80.230.95 CRV, INC. 1607 LaPorte Rd Waterloo, IA 50702 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. 2022-07-15 Leonard Wayne Corpman priorityone@thewebunwired.com Cedar Falls Black Hawk IA John W Vinton Stephen A Brustkern Signed (1) The corporation rejects the employers’ liability coverage. Leonard Wayne Corpman priorityone@thewebunwired.com Officer Cedar Falls Black Hawk IA John W Vinton Stephen A Brustkern Signed
512 2022-07-15 11:45 Anonymous (not verified) 50.80.230.95 CRV, Inc 1607 LaPorte Rd Waterloo, IA 50702 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. 2022-07-15 Maureen Louise Corpman priorityone@thewebunwired.com Cedar Falls Black Hawk IA John W Vinton Stephen A Brustkern Signed (1) The corporation rejects the employers’ liability coverage. Maureen Louise Corpman priorityone@thewebunwired.com Officer Cedar Falls Black Hawk IA John W Vinton Stephen A Brustkern Signed
514 2022-07-15 11:51 Anonymous (not verified) 50.80.230.95 CRV, Inc 1607 LaPorte Rd Waterloo, IA 50702 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. 2022-07-15 Brett Allyn Corpman priorityone@thewebunwired.com Waterloo Black Hawk Iowa John W Vinton Stephen A Brustkern Signed (1) The corporation rejects the employers’ liability coverage. Brett Allyn Corpman priorityone@thewebunwired.com Officer Waterloo Black Hawk IA John W Vinton Stephen A Brustkern Signed
572 2022-11-17 16:43 Anonymous (not verified) 204.16.59.133 Washland, Inc. 4050 W Schrock Rd, Hudson, IA 50643 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. 2022-11-17 Steven Douglas Barfels getclean@laundryplusiowa.com Hudson Black Hawk Iowa Joel Steven Barfels Vicki Lorraine Barfels Signed (1) The corporation rejects the employers’ liability coverage. Joel Steven Barfels joel@laundryplusiowa.com Corporate Secretary Hudson Black Hawk Iowa Joel Steven Barfels Vicki Lorraine Barfels Signed
573 2022-11-17 16:46 Anonymous (not verified) 204.16.59.133 Washland, Inc. 4050 W Schrock Rd, Hudson, IA 50643 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. 2022-11-17 Vicki Lorraine Barfels vicki@laundryplusiowa.com Hudson Black Hawk Iowa Joel Steven Barfels Steven Douglas Barfels Signed (1) The corporation rejects the employers’ liability coverage. Joel Steven Barfels joel@laundryplusiowa.com Corporate Secretary Hudson Black Hawk Iowa Joel Steven Barfels Steven Douglas Barfels Signed
574 2022-11-17 16:48 Anonymous (not verified) 204.16.59.133 Washland, Inc. 4050 W Schrock Rd, Hudson, IA 50643 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. 2022-11-17 Joel Steven Barfels joel@laundryplusiowa.com Hudson Black Hawk Iowa Vicki Lorraine Barfels Steven Douglas Barfels Signed (1) The corporation rejects the employers’ liability coverage. Vicki Lorraine Barfels vicki@laundryplusiowa.com Corporate Treasurer Hudson Black Hawk Iowa Vicki Lorraine Barfels Steven Douglas Barfels Signed
600 2023-02-16 16:06 Anonymous (not verified) 94.188.207.225 Friday After Work LLC 2526 Rainbow Drive, Cedar Falls, IA 50613 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. 2023-01-01 Joshua Carder josh.cve@gmail.com Cedar Falls Black Hawk Iowa Brady Huls Tyler Reynolds Signed (1) The corporation rejects the employers’ liability coverage. Brent Dunlop fawconstruction.ia@gmail.com Owner Cedar Falls Black Hawk Iowa Brady Huls Tyler Reynolds Signed
601 2023-02-16 16:08 Anonymous (not verified) 94.188.207.223 Friday After Work LLC 2526 Rainbow Drive, Cedar Falls, IA 50613 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. 2023-01-01 Tyler Reynolds tyler.cve@gmail.com Cedar Falls Black Hawk Iowa Brady Huls Joshua Carder Signed (1) The corporation rejects the employers’ liability coverage. Brent Dunlop fawconstruction.ia@gmail.com Owner Cedar Falls Black Hawk Iowa Brady Huls Joshua Carder Signed
602 2023-02-16 16:10 Anonymous (not verified) 94.188.207.228 Friday After Work LLC 2526 Rainbow Drive, Cedar Falls, IA 50613 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. 2023-01-01 Brady John Huls brady.cve@gmail.com Cedar Falls Black Hawk Iowa Tyler Reynolds Joshua Carder Signed (1) The corporation rejects the employers’ liability coverage. Brent Dunlop fawconstruction.ia@gmail.com Owner Cedar Falls Black Hawk Iowa Tyler Reynolds Joshua Carder Signed
603 2023-02-16 16:11 Anonymous (not verified) 94.188.207.223 Transcend Mind Body Wellness and Floatation Clinic 409 Washington Street, Cedar Falls, IA 50613 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. 2023-01-01 Morgan Huls transcendcedarfalls@gmail.com Cedar Falls Black Hawk Iowa Brady Huls Ashlyn Henry Signed (1) The corporation rejects the employers’ liability coverage. Brady Huls transcendcfo@gmail.com CFO Cedar Falls Black Hawk Iowa Morgan Huls Ashlyn Henry Signed
604 2023-02-16 16:13 Anonymous (not verified) 94.188.207.226 Transcend Mind Body Wellness and Floatation Clinic 409 Washington Street, Cedar Falls, IA 50613 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. 2023-01-01 Brady Huls brady.huls@gmail.com Cedar Falls Black Hawk Iowa Morgan Huls Ashlyn Henry Signed (1) The corporation rejects the employers’ liability coverage. Morgan Huls transcendcedarfalls@gmail.com Owner Cedar Falls Black Hawk Iowa Brady Huls Ashlyn Henry Signed
607 2023-02-20 21:53 Anonymous (not verified) 94.188.207.223 Rancheros construction LLC 1121 Linn Street 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. 2022-09-15 Salvador Alvarez rancherosconstruction@outlook.com Waterloo Black hawk Iowa Adan Antonio Signed (1) The corporation rejects the employers’ liability coverage. Salvador Alvarez rancherosconstruction@outlook.com Owner Waterloo Black hawk Iowa Adan Antonio Signed
661 2023-04-29 10:04 Anonymous (not verified) 94.188.205.177 Planetary Tree Service 166 Brovan blvd, evansdale, iowa 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. 2023-04-29 Andrew Jon Collins thetreeguy2000@gmail.com Evansdale Black Hawk Iowa Jennifer Selleck Carolyn Inman Signed (1) The corporation rejects the employers’ liability coverage. Andrew Jon Collins thetreeguy2000@gmail.com Owner Evansdale Black hawk Iowa Jennifer renee selleck Carolyn kay Inman Signed
682 2023-06-07 16:10 Anonymous (not verified) 94.188.207.223 Jake's Insulation Inc. 2020 Valley High Dr. Cedar Falls, IA 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. 2023-06-07 Jacob Ryan Smalley jakersmalley@gmail.com Cedar Falls Black Hawk Iowa Emily D Smalley Allison L Smalley Signed (1) The corporation rejects the employers’ liability coverage. Jacob Ryan Smalley jakersmalley@gmail.com President Cedar Falls Black Hawk Iowa Emily Smalley Allison Smalley Signed
749 2023-08-20 16:36 Anonymous (not verified) 94.188.207.225 Wonderfully Made LLC 2003 Downing Ave Waterloo IA 50701 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. 2023-08-20 Víctor Manuel Martinez Jr. martinezvic54@gmail.com Waterloo Black Hawk IA Trey Patterson Lauren Shaff Signed (1) The corporation rejects the employers’ liability coverage. Alexis Lise Martinez victorandleximartinez@gmail.com Owner Waterloo Black Hawk IA Trey Patterson Lauren Shaff Signed
750 2023-08-20 16:41 Anonymous (not verified) 94.188.207.229 Wonderfully Made LLC 2003 Downing Ave Waterloo IA 50701 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. 2023-08-20 Alexis Lise Martinez victorandleximartinez@gmail.com Waterloo Black Hawk IA Trey Patterson Lauren Shaff Signed (1) The corporation rejects the employers’ liability coverage. Alexis Lise Martinez victorandleximartinez@gmail.com Owner Waterloo Black Hawk IA Trey Patterson Lauren Shaff 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
904 2024-02-28 06:52 Anonymous (not verified) 94.188.205.167 Monarca General Builders LLC. 551 Martin Rd 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. 2023-12-28 Antonio Serrato Sánchez assmsaeaj@icloud.com Waterloo Black Hawk Iowa Maria santos Juarez Adan Alvarez Signed (1) The corporation rejects the employers’ liability coverage. Antonio Serrato Sánchez assmsaeaj@icloud.com President Waterloo Black Hawk Iowa Maria santos Juarez Adan Alvarez Signed
905 2024-02-28 11:47 Anonymous (not verified) 94.188.207.228 Monarca General Builders LLC 551 Martin Rd 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. 2024-01-01 Antonio Serrato Sánchez assmsaeaj@icloud.com Waterloo Black Hawk Iowa Maria santos Juarez Adan Alvarez Signed (1) The corporation rejects the employers’ liability coverage. Antonio Serrato Sánchez assmsaeaj@icloud.com Presidente Waterloo Black Hawk Iowa Maria santos Juarez Adan Alvarez Signed
354 2021-11-04 16:26 Anonymous (not verified) 97.64.194.58 D&D Construction 1124 West Donald ST, Waterloo IA 50703 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. 2021-11-04 Darrel Caldwell dcaldwell1124@yahoo.com Waterloo Black Hawk County IA Scott Joseph Demuth Catrese Caldwell Signed (1) The corporation rejects the employers’ liability coverage. NA dcaldwell1124@yahoo.com NA NA NA NA NA NA Signed
552 2022-10-03 11:50 Anonymous (not verified) 173.18.48.197 Rancheros construction LLC 1121 Linn Street 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. 2022-09-25 Salvador Alvarez rancherosconstruction@outlook.com Waterloo Black hwak Iowa Jose Sergio Signed (1) The corporation rejects the employers’ liability coverage. Salvador Alvarez rancherosconstruction@outlook.com N/a Waterloo Black hawk Iowa Jose Sergio Signed
58 2020-04-14 08:32 Anonymous (not verified) 174.217.17.57 Society of St Vincent de Paul, District Counsel Waterloo Iowa 320 Broadway St PO Box 2727 Waterloo IA 50704 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. 2020-04-14 Rodney Crowe crorod@aol.com Waterloo Blackhawk Iowa George W Karnivk Glynis R Worthington Signed (1) The corporation rejects the employers’ liability coverage. Joseph D Sobczyk joczyk@aol.com Corporate Treasurer Cdear Falls Blackhawk Iowa George W Karnick Glynis R Worthington Signed
533 2022-09-08 11:04 Anonymous (not verified) 174.198.66.66 WCDEVINE LLC dba Five Star Painting of Cedar Falls 6333 Leversee Road 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. 2022-09-08 Wade Devine (owner) Wade.Devine@fivestarpainting.com Waterloo Blackhawk Iowa Brad Johnson Tom Wildeboer Signed (1) The corporation rejects the employers’ liability coverage. Wade Devine Wade.Devine@fivestarpainting.com Owner/Same person Waterloo Blackhawk Iowa Brad Johnson Tom Wildeboer Signed
537 2022-09-20 09:01 Anonymous (not verified) 173.20.206.50 Accent Painting LLC 613 Locust 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. 2022-09-20 Anthony Gilbert Gasco accentpainting@yahoo.com La Porte City Blackhawk Iowa Arthur Rudolf Gasco Aurora Jealee Gasco Signed (1) The corporation rejects the employers’ liability coverage. Anthony Gilbert Gasco accentpainting@yahoo.com Owner La Porte City Blackhawk Iowa Arthur Rudolf Gasco Aurora Jealee Gasco Signed
967 2024-05-01 06:30 Anonymous (not verified) 94.188.207.224 Cael Gulrud 206 W Main St Calmar, IA, 52132 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. 2024-05-01 Brandon Gulrud mojopants21@gmail.com Waterloo Blackhawk IA Victoria Bacon-Ortiz David Gulrud Signed (1) The corporation rejects the employers’ liability coverage. Cael Gulrud gulrud8728@gmail.com Owner Calmar Winneshiek IA Victoria Bacon-Ortiz David Gulrud Signed
739 2023-08-11 18:02 Anonymous (not verified) 94.188.205.176 Frontline Roofing & Construction LLC 310 W Gilbert Dr 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. (2) I decline to reject the employer’s liability coverage. 2023-08-10 Verónica Santos FrontlineR-C@outlook.com Evansdale BlackHawk County IA Angela Hernandez Kevi Hernandez Signed (2) The corporation declines to reject the employers’ liability coverage. Veronica Santos angelasermeno@gmail.com Owner Evansdale BlackHawk IA Angela Hernandez Signed
32 2020-01-14 10:33 Anonymous (not verified) 108.171.132.189 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 Travis Garrett onethird4599@gmail.com Boone Boone Iowa Katie Frame Jessica Carroll Signed (1) The corporation rejects the employers’ liability coverage. Travis Garrett onethird4599@gmail.com Owner Boone Boone IOWA Katie Frame Jessica Carroll 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
402 2022-02-09 09:46 Anonymous (not verified) 69.57.33.202 Toby K's Hideaway Inc. dba Toby K's Hideaway 1723 Mamie Eisenhower Ave, 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. 2022-02-09 Toby Kruse samanthapeck@boehmins.com Boone Boone Iowa Samantha Peck Hans Boehm Signed (1) The corporation rejects the employers’ liability coverage. Toby Kruse samanthapeck@boehmins.com Owner Boone Boone Iowa Samantha Peck Hans Boehm Signed
663 2023-05-03 12:53 Anonymous (not verified) 94.188.205.177 Seven Oaks Recreation 1086 222nd Dr., 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. 2023-05-03 Joel Bryan joel@sevenoaksrec.com Ogden Boone United States Anthony Calek Craig Christensen Signed (1) The corporation rejects the employers’ liability coverage. Sara Bryan sara@sevenoaksre.com Director/Vice-President/Secretary Boone Boone United States Anthony Calek Craig Christensen Signed
664 2023-05-03 12:54 Anonymous (not verified) 94.188.205.174 Seven Oaks Recreation 1086 222nd Dr., 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. 2023-05-03 Sara Bryan sara@sevenoaksrec.com Ogden Boone Iowa Anthony Calek Craig Christensen Signed (1) The corporation rejects the employers’ liability coverage. Sara Bryan sara@sevenoaksre.com Director/Vice-President/Secretary Boone Boone United States Anthony Calek Craig Christensen Signed
665 2023-05-03 12:54 Anonymous (not verified) 94.188.205.169 Seven Oaks Recreation 1086 222nd Dr., 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. 2023-05-03 Joel Bryan joel@sevenoaksrec.com Ogden Boone Iowa Anthony Calek Craig Christensen Signed (1) The corporation rejects the employers’ liability coverage. Sara Bryan sara@sevenoaksre.com Director/Vice-President/Secretary Boone Boone United States Anthony Calek Craig Christensen Signed
768 2023-09-12 12:48 Anonymous (not verified) 94.188.207.224 BSSI MW 23959 580th 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. 2023-08-28 Tom Barragy tom@agvolution.co Ames Boone Iowa Blaine Bancks Pete Romig Signed (1) The corporation rejects the employers’ liability coverage. Thomas j Barragy tbarragy@agvolution.co ownet AMES Boone ia Blaine Bancks Pete Romig Signed
863 2024-01-23 13:59 Anonymous (not verified) 94.188.205.176 United Marble & Tile, Inc. 915 8th Street, #201, 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. 2024-01-24 Albert James Gotta jim@umtile.com Slater Boone IA Antonina M Gotta MARY KATE RUSSELL Signed (1) The corporation rejects the employers’ liability coverage. Albert James Gotta jim@umtile.com President Sole Share Holder Boone IA IA Antonina M Gotta Antonina M Gotta Signed
412 2022-02-23 15:42 Anonymous (not verified) 208.126.112.220 Bergmann Bros. Excavating & Trucking PO Box G, Frederika, IA 50631 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. 2022-02-23 Kenny A. Bergmann kennb@butler-bremer.com Frederika Bremer Iowa Ronald A. Bergmann Tad M. Chapin Signed (1) The corporation rejects the employers’ liability coverage. Kenny A. Bergmann kennb@butler-bremer.com self Frederika Bremer Iowa Ronald A. bergmann Tad M. Chapin 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
779 2023-10-04 07:14 Anonymous (not verified) 94.188.207.225 CanD Homes, LLC 1147 Leitha Ter, Waverly, IA 50677 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. 2023-10-04 Alexander Eckard-Lewis alex.lewis@candhomes.com Waverly Bremer IA Connor Eustice Victor Sanders Signed (1) The corporation rejects the employers’ liability coverage. Alexander Eckard-Lewis alex.lewis@candhomes.com Vice President Waverly Bremer IA Connor Eustice Victor Sanders Signed
336 2021-09-16 18:53 Anonymous (not verified) 64.142.5.50 Electrious Inc DBA Clean Tech 1110 Alhambra Ave Martinez CA 94533. 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. 2021-08-26 Petr Brazdil petr.brazdil@clean.tech Trida Spojencu Brno Czechia in Europe Robbie Lemos Teresa Leibnitz Signed (1) The corporation rejects the employers’ liability coverage. Robbie Lemos robbie.lemos@clean.tech CEO SAN RAMON Contra Costa County CA Robbie Lemos Teresa Leibnitz Signed
214 2021-03-28 12:59 Anonymous (not verified) 172.86.34.18 Agronomic Solutions, INC 1614 Fir Avenue Coon Rapids, IA 50058 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 Nickolas Lee Steffens nsteffens@agsolutionsinc.net Quasqueton Buchanan Iowa Julia Sperfslage Andrew Sperfslage Signed (1) The corporation rejects the employers’ liability coverage. Nickolas Lee Steffens nsteffens@agsolutionsinc.net Owner/ Vice President Quasqueton Buchanan Iowa Andrew Sperfslage Julia Sperfslage Signed
464 2022-05-06 10:15 Anonymous (not verified) 172.86.44.178 Cornhill Express LLC 6472 40th St, Aurora, IA 50607 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. 2022-05-06 Jamie Fettkether sales@cherepair.com Aurora Buchanan Iowa Ben Hogan Ryan Peyton Signed (1) The corporation rejects the employers’ liability coverage. Jamie Fettkether sales@cherepair.com Owner Aurora Buchanan Iowa Ben Hogan Ryan Peyton Signed
122 2020-10-05 15:21 Anonymous (not verified) 173.24.190.134 Greg Haldin Construction, Inc. PO Box 387, Sioux Rapids, IA 50585 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. 2020-10-06 Greg Haldin ghconstruction@live.com Sioux Rapids Buena Vista IA Candie Clark Scott Wirtz Signed (1) The corporation rejects the employers’ liability coverage. Greg Haldin ghconstruction@live.com President Sioux Rapids Buena Vista IA Candie Clark Scott Wirtz Signed
149 2020-12-31 14:59 Anonymous (not verified) 216.81.153.249 S&A Holdings LLC 115 N 2nd Street, Fort Dodge, IA 50501 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. 2020-12-21 Surinder Kumar NONE@GMAIL.COM Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Surinder Kumar NONE@GMAIL.COM Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
150 2020-12-31 15:00 Anonymous (not verified) 216.81.153.249 S&A Holdings LLC 115 N 2nd Street, Fort Dodge, IA 50501 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. 2020-12-21 Amritpal Singh amritaust1@gmail.com Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Amritpal Singh amritaust1@gmail.com Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
155 2021-01-06 15:50 Anonymous (not verified) 216.81.153.249 Al's Inc DWB CW&T 1509 Richland Drive, Storm Lake, IA 5058 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. 2020-12-29 Robert Bauer NONE@GMAIL.COM Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Robert Bauer NONE@GMAIL.COM Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
156 2021-01-06 15:52 Anonymous (not verified) 216.81.153.249 Al's Inc DWB CW&T 1509 Richland Drive, Storm Lake, IA 5058 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. 2020-12-29 Jon Bauer NONE@GMAIL.COM Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Jon Bauer None@gmail.com Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
157 2021-01-06 15:53 Anonymous (not verified) 216.81.153.249 Al's Inc DWB CW&T 1509 Richland Drive, Storm Lake, IA 5058 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. 2020-12-29 April Coleman NONE@GMAIL.COM Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. April Coleman None@gmail.com Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
158 2021-01-06 15:54 Anonymous (not verified) 216.81.153.249 Al's Inc DWB CW&T 1509 Richland Drive, Storm Lake, IA 5058 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. 2020-12-29 Julie Deucker NONE@GMAIL.COM Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Julie Duecker None@gmail.com Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
338 2021-09-22 10:34 Anonymous (not verified) 216.81.153.249 APS LLC 904 Lake Avenue 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. 2021-09-22 Amrit Singh amritaust1@gmail.com Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Amrit Singh amritaust1@gmail.com Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
372 2021-12-09 14:17 Anonymous (not verified) 204.155.61.217 Buena Vista Auto Sales Inc 1030 Lake Ave, Storm Lake, IA 50588 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. 2021-12-09 Arturo Lozano bvusedcars@siouxland.com Storm Lake Buena Vista IA Jared Brashears Michelle Munoz Signed (1) The corporation rejects the employers’ liability coverage. Arturo Lozano bvusedcars@siouxland.com Owner storm Lake Buena Vista IA Jared Brashears Michelle Munoz Signed
724 2023-08-02 16:09 Anonymous (not verified) 94.188.207.223 Magnussen Bros Inc 1945 560th Street, Newell, IA 50568 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. 2023-08-02 Duane Magnussen dcmag@ncn.net Newell Buena Vista Iowa Jared Brashears Katie Gunkelman Signed (1) The corporation rejects the employers’ liability coverage. Duane Magnussen ncmag@ncn.net Owner Newell Buena Vista IA Jared Brashears Katie Gunkelman Signed
973 2024-05-03 11:24 Anonymous (not verified) 94.188.207.227 Trent Hatlen 1042 490th Street, Rembrandt, IA 50576 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. 2024-05-03 Trent Hatlen trentgotti@yahoo.com Rembrandt Buena Vista Iowa Jared Brashears Katie Gunkelman Signed (1) The corporation rejects the employers’ liability coverage. Trent Hatlen trentgotti@yahoo.com Owner Rembrandt Buena Vista Iowa Jared Brashears Katie Gunkelman Signed
965 2024-04-30 10:47 Anonymous (not verified) 94.188.205.177 Billy Dudock 148818 Argo Fay Rd 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. 2024-04-30 Billy Dudock mitzi@bruggemanlumber.com Thompson Carroll IL Roger Gibbs Mitzi Hoeger Signed (1) The corporation rejects the employers’ liability coverage. Billy Dudock mitzi@bruggemanlumber.com Self Thompson Carroll Il Roger Gibbs Mitzi Hoeger Signed
570 2022-11-16 10:35 Anonymous (not verified) 50.81.253.108 XU's Golden Dragon 508 Chestnut St., Atlantic, IA 50022 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. 2022-11-16 Xu Long 125529647@QQ.COM Atlantic Cass IA Richard Crall Shannon Crall Signed (1) The corporation rejects the employers’ liability coverage. Richard Crall richard@partnersins.com Insurance Agent Atlantic Cass United States Shannon Crall Richard Crall Signed
571 2022-11-16 10:40 Anonymous (not verified) 50.81.253.108 XU's Golden Dragon 508 Chestnut St., Atlantic, IA 50022 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. 2022-11-16 Tingjie Huang 125529647@QQ.COM Atlantic Cass IA Richard Crall Shannon Crall Signed (1) The corporation rejects the employers’ liability coverage. Richard Crall richard@partnersins.com Insurance Agent Atlantic Cass United States Shannon Crall Richard Crall 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
472 2022-05-13 11:19 Anonymous (not verified) 69.18.19.139 BES, Inc. 1615 E Washington St, Mt Pleasant, IA 52641 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. 2022-05-13 Todd Baldridge todd.baldridge@beswatersolutions.com West Branch Cedar Iowa Nicholas Baldridge Owen Baldridge Signed (1) The corporation rejects the employers’ liability coverage. Randy Seberg randy.seberg@beswatersolutions.com Managing Director Mt Pleasant Henry IA John Rodewald Matt Mowery Signed
626 2023-03-16 11:18 Anonymous (not verified) 94.188.207.224 Raymond Carpenter 1655 230th St Tipton IA 52772 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. 2023-03-16 Raymond Carpenter badseedmudraching@gmail.com Tipton Cedar Iowa Mitzi Hoeger Roger Gibbs Signed (1) The corporation rejects the employers’ liability coverage. Raymond Carpenter badseedmudracing@gmail.com Self Tipton Cedar IA Roger Gibbs Mitzi Hoeger Signed
713 2023-07-25 12:26 Anonymous (not verified) 94.188.205.174 HT&T Drywall 479 old lincoln hwy Mechanicsville 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. 2023-07-25 Tracy Spray tspray9@hotmail.com Mechanicsville Cedar Iowa Dillon Williams Leighton Raplinger Signed (1) The corporation rejects the employers’ liability coverage. Tracy Spray tspray9@hotmail.com Owner Mechanicsville Cedar Iowa Dillon Williams Leighton Raplinger Signed
718 2023-07-27 08:43 Anonymous (not verified) 94.188.207.225 HT&T Drywall 479 Old Lincoln Hwy 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. 2023-07-27 Tracy Spray tspray9@hotmail.com Mechanicsville Cedar Iowa Dillon Williams Leighton Raplinger Signed (1) The corporation rejects the employers’ liability coverage. Tracy Spray tspray9@hotmail.com Owner Mechanicsville Cedar Iowa Dillon Williams Leighton Raplinger Signed
813 2023-11-14 13:00 Anonymous (not verified) 94.188.207.226 NeX Level Moving, LLC 5634 Deerwood St. SW, Cedar Rapids, IA, 52404 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. 2023-11-14 Garrett Allen Reno garrettreno2001@gmail.com Tipton Cedar Iowa Bridget Camp Tarin Erenberger Signed (1) The corporation rejects the employers’ liability coverage. Tarin Erenberger tarin.nexlevelusa@gmail.com Operations Director Cedar Rapids Linn Iowa Bridget Camp Garrett Reno Signed
814 2023-11-14 13:11 Anonymous (not verified) 94.188.207.225 NeX Level Moving, LLC 5634 Deerwood St. SW, Cedar Rapids, IA, 52404 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. 2023-11-14 Garrett Allen Reno garrettreno2001@gmail.com Tipton Cedar Iowa Bridget Camp Tarin Erenberger Signed (1) The corporation rejects the employers’ liability coverage. Garrett Reno garrettreno2001@gmail.com Self Tipton Cedar Iowa Bridget Camp Tarin Erenberger Signed
899 2024-02-25 18:18 Anonymous (not verified) 94.188.207.229 Michael D Clark 324 main st Bennett Iowa 52721 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. 2024-02-25 Michael D Clark michaeld3705@gmail.com Bennett Cedar Iowa Davia Dawn Kelley Tabetha Jean Widmer Signed (1) The corporation rejects the employers’ liability coverage. Michael D Clark michaeld3705@gmail.com Owner Bennett Cedar Iowa Davia Dawn Kelley Tabetha Jean Widmer Signed
906 2024-02-29 16:16 Anonymous (not verified) 94.188.205.168 Bradley K. Gaul Handyman Services 740 Cedar Valley Road, Tipton, IA 52772 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. 2024-02-29 Bradley Keith Gaul bjgjal33@aol.com Tipton Cedar Iowa Jill Lynette Gaul Logan Benjamin Gaul Signed (1) The corporation rejects the employers’ liability coverage. Bradley Keith Gaul bjgjal33@aol.com Self Tipton Cedar Iowa Jill Lynette Gaul Logan Benjamin Gaul Signed
907 2024-03-01 12:13 Anonymous (not verified) 94.188.207.230 Bulls Eye Builders Llc 406 E South st Mechanicsville 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. 2024-03-01 Timothy Hansel bullseyebuildersllc@gmail.com Mechanicsville Cedar Iowa Kevin Kofron Jackie hart Signed (1) The corporation rejects the employers’ liability coverage. Timothy Hansel bullseyebuildersllc@gmail.com Owner Mechanicsville Iowa United States Kevin Kofron Jackie Hart Signed
83 2020-05-20 12:34 Anonymous (not verified) 108.171.131.188 North Iowa Custom Seamless Guttering, Inc PO Box 512, 1300 2nd Ave S, Clear Lake, Iowa 50428 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. 2020-05-20 Keith E Main keithmaincsg@hotmail.com Clear Lake Cerro Gordo Iowa Lloyd L Heinselman Diane K Harrington Signed (1) The corporation rejects the employers’ liability coverage. Keith E Main keithmaincsg@hotmail.com President Clear Lake Cerro Gordo Iowa Lloyd L Heinselman Diane K Harrington Signed
233 2021-04-13 10:35 Anonymous (not verified) 172.83.18.1 Skyway Inc 7030 27th Way, Clear Lake, IA 50428 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. 2021-03-06 Brad Thompson mary@skywaypropertyinspections.com Clear Lake Cerro Gordo Iowa Becky Plagge Deb Otto Signed (1) The corporation rejects the employers’ liability coverage. Brad Thompson mary@skywaypropertyinspections.com Owner Clear Lake Cerro Gordo Iowa Becky Plagge Deb Otto Signed
234 2021-04-13 10:37 Anonymous (not verified) 172.83.18.1 Skyway Inc 7030 27th Way, Clear Lake, IA 50428 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. 2021-03-06 Mary Thompson mary@skywaypropertyinspections.com Clear Lake Cerro Gordo Iowa Becky Plagge Deb Otto Signed (1) The corporation rejects the employers’ liability coverage. Brad Thompson mary@skywaypropertyinspections.com Owner Clear Lake Cerro Gordo Iowa Becky Plagge Deb Otto Signed
245 2021-04-22 10:54 Anonymous (not verified) 172.83.18.1 Skyway Inc 7030 27th Way, Clear Lake, IA 50428 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. 2021-04-22 Brad Thompson becky@fgains.com Clear Lake Cerro Gordo Iowa Debbie Otto Paxton Farmer Signed (1) The corporation rejects the employers’ liability coverage. Brad Thompson becky@fgains.com Owner Clear Lake Cerro Gordo Iowa Debbie Otto Paxton Farmer Signed
246 2021-04-22 10:56 Anonymous (not verified) 172.83.18.1 Skyway Inc 7030 27th Way, Clear Lake, IA 50428 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. 2021-04-22 Mary Thompson becky@fgains.com Clear Lake Cerro Gordo Iowa Debbie Otto Paxton Farmer Signed (1) The corporation rejects the employers’ liability coverage. Brad Thompson becky@fgains.com Owner Clear Lake Cerro Gordo Iowa Debbie Otto Paxton Farmer Signed