900 |
2024-02-26 11:00 |
Anonymous (not verified) |
94.188.207.226 |
roorda dairy llc |
5128 460th 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. |
2024-02-22 |
lance roorda |
lgroorda@gmail.com |
sioux center |
sioux county |
iowa |
larry roorda |
scott roorda |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
kyle blankers |
kyle@veinsurance.com |
member |
5128 460th st |
obrien county |
iowa |
larry roorda |
scott roorda |
Signed |
901 |
2024-02-26 11:02 |
Anonymous (not verified) |
94.188.207.227 |
roorda dairy llc |
5128 460th 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. |
2024-02-22 |
larry roorda |
lgroorda@gmail.com |
paullina |
obrien county |
iowa |
lance roorda |
scott roorda |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
kyle blankers |
kyle@veinsurance.com |
member |
5128 460th st |
obrien county |
iowa |
lance roorda |
scott roorda |
Signed |
902 |
2024-02-26 11:37 |
Anonymous (not verified) |
94.188.207.228 |
roorda dairy llc |
5128 460th 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. |
2024-02-22 |
scott roorda |
scottyroorda@hotmail.com |
granville |
obrien county |
iowa |
lance roorda |
larry roorda |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
kyle blankers |
kyle@veinsurance.com |
member |
5128 460th st |
obrien county |
iowa |
lance roorda |
larry roorda |
Signed |
400 |
2022-02-04 10:37 |
Anonymous (not verified) |
173.16.199.106 |
Paradigm Construction |
960 Pelican Drive – Polk City, IA 50226 |
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. |
2022-02-04 |
MATTHEW HENDRICKSON |
matthendrickson88@gmail.com |
NORWALK |
IA |
United States |
Richard Green |
Sheldon Thompson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ryan Shabino |
ryan@prdgmconstruction.com |
Contractor |
960 Pelican Drive – Polk City, IA 50226 |
Polk |
Iowa |
Richard Green |
Sheldon Thompson |
Signed |
244 |
2021-04-21 15:01 |
Anonymous (not verified) |
63.152.5.170 |
Berghuis Trucking Inc. |
14526 U Ave Ackley Iowa 50601 |
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. |
2021-04-21 |
Justin Berghuis |
justinberghuis@gmail.com |
Ackley |
Hardin |
Iowa |
Thomas Beving |
Lindsey Beving |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Justin Berghuis |
justinberghuis@gmail.com |
owner |
Ackley |
Hardin |
Iowa |
Thomas Beving |
Lindsey Beving |
Signed |
617 |
2023-03-02 18:39 |
Anonymous (not verified) |
94.188.205.167 |
Fosters woodworking and design llc |
26498 g ave, adel ia 50003 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-02 |
Nicholas Foster |
nick@fosterswooddesign.com |
Adel |
Dallas |
Iowa |
Tanya Foster |
Mike Merrick |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nicholas Foster |
nfoster1988@icloud.com |
Owner |
Adel |
Dallas |
Iowa |
Tanya foster |
Mike merrick |
Signed |
937 |
2024-03-30 17:30 |
Anonymous (not verified) |
94.188.205.167 |
AR Drilling LLC |
1821 Roebling Rd, Adel, IA 50003 |
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. |
2024-03-30 |
Luis Serrano |
serranoluis7667@gmail.com |
Adel |
Dallas |
IA |
Kelly green |
Thomas Green |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Luis Serrano |
serranoluis7667@gmail.com |
Owner |
Adel |
Dallas |
IA |
Kelly Green |
Thomas Green |
Signed |
945 |
2024-04-03 20:00 |
Anonymous (not verified) |
94.188.207.229 |
Timberview Construction |
803 TIMBERVIEW 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. |
(1) I reject the employers’ liability coverage. |
2024-04-03 |
Parker Evans |
Pcevans28@gmail.com |
ADEL |
IA |
United States |
jason Evans |
Tricia Evans |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Timberview Construction |
Pcevans28@gmail.com |
Myself |
ADEL |
IA |
United States |
Jason Evans |
Tricia Evans |
Signed |
743 |
2023-08-15 15:03 |
Anonymous (not verified) |
94.188.205.177 |
R & T Trucking LLC |
1374 Creamery Road, Afton Iowa 50830 |
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. |
2023-08-15 |
Robert Dike |
robandteenadike@outlook.com |
Afton |
Union |
Iowa |
Kristina Dike |
Robert Dike |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Dike |
robandteenadike@outlook.com |
Owner |
Afton |
Union |
Iowa |
Kristina Dike |
Robert Dike |
Signed |
930 |
2024-03-21 20:44 |
Anonymous (not verified) |
94.188.207.229 |
Southeast Iowa Precision Painting |
714 Lincoln St Ainsworth IA 52201 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-21 |
Kirby Jay Shetler |
kirbyshetler@gmail.com |
Ainsworth |
Washington |
Iowa |
Kirby Shetler |
Demi Shetler |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Southeast Iowa Precision Painting |
kirbyshetler@gmail.com |
Owner |
Ainsworth |
Washington |
Iowa |
Kirby Shetler |
Demi Shetler |
Signed |
116 |
2020-09-11 11:42 |
Anonymous (not verified) |
69.57.22.68 |
Brush and Weed Control Specialists, Inc. |
1108 230th Street - Algona, IA 50511 |
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. |
2020-09-11 |
Ruth Jean Lindgren |
bwcontrol@netamumail.com |
Algona |
Kossuth |
Iowa |
James Black |
Katie Melvin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Donald H Reffer |
bwcontrol@netamumail.com |
President and General Manager |
Algona |
Kossuth |
Iowa |
James Black |
Katie Melvin |
Signed |
142 |
2020-12-02 09:39 |
Anonymous (not verified) |
208.90.15.53 |
Humboldt Community Daycare, Inc. DBA Kiddie Cats Childcare and Learning Center |
P.O. Box 93 Dakota City, Ia 50529 |
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. |
2020-12-02 |
Angelique Berry |
dcity@goldfieldaccess.net |
Algona |
Kossuth |
Iowa |
Ross Sleiter |
Scott Curran |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Angelique Berry |
dcity@goldfieldaccess.net |
Secretary/Treasurer |
Algona |
Kossuth |
Iowa |
Ross Sleiter |
Scott Curran |
Signed |
622 |
2023-03-08 13:40 |
Anonymous (not verified) |
94.188.207.226 |
DDD Construction |
624 west maple P.O.164 Allerton |
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. |
2023-03-08 |
Douglas Dean Downs |
tripledconstruction@hotmail.com |
ALLERTON |
IA |
United States |
June Lynette Downs |
William Lee Downs |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Douglas Dean Downs |
tripledconstruction@hotmail.com |
Coowner |
ALLERTON |
IA |
United States |
June Lynette Downs |
William Lee Downs |
Signed |
88 |
2020-06-10 11:36 |
Anonymous (not verified) |
173.28.7.32 |
DMG INSTALLATIONS INC |
5534 NE 17TH ST #4 |
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. |
2020-06-10 |
DAVID PAUL DUNLAP |
HAYDAVE@AOL.COM |
DES MOINES |
POLK |
IOWA |
JASON DAVID MUSSO |
CLIFFORD LEE BAKER |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CLIFF BAKER |
CLBAKER@MEDIACOMBB.NET |
PRESIDENT |
ALTOONA |
POLK |
IOWA |
JASON DAVID MUSSO |
DAVID PAUL DUNLAP |
Signed |
89 |
2020-06-10 11:42 |
Anonymous (not verified) |
173.28.7.32 |
DMG INSTALLATIONS INC |
5534 NE 17TH ST #4 |
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. |
2020-06-10 |
JASON DAVID MUSSO |
JMUSSO74@GMAIL.COM |
BONDURANT |
POLK |
IOWA |
DAVID PAUL DUNLAP |
CLIFFORD LEE BAKER |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CLIFFORD LEE BAKER |
CLBAKER@MEDIACOMBB.NET |
PRESIDENT |
ALTOONA |
POLK |
IOWA |
JASON DAVID MUSSO |
DAVID PAUL DUNLAP |
Signed |
90 |
2020-06-10 11:46 |
Anonymous (not verified) |
173.28.7.32 |
DMG INSTALLATIONS INC |
5534 NE 17TH ST #4 |
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. |
2020-06-10 |
CLIFFORD LEE BAKER |
CLBAKER@MEDIACOMBB.NET |
ALTOONA |
POLK |
IOWA |
DAVID PAUL DUNLAP |
JASON DAVID MUSSO |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CLIFFORD LEE BAKER |
CLBAKER@MEDIACOMBB.NET |
PRESIDENT |
ALTOONA |
POLK |
IOWA |
JASON DAVID MUSSO |
DAVID PAUL DUNLAP |
Signed |
171 |
2021-01-26 15:07 |
Anonymous (not verified) |
174.198.73.28 |
R. A. Snow Removals, Inc |
525 7th St. 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. |
2021-01-26 |
Robert Aaron Snow |
rasnowremovals.inc@gmail.com |
Altoona |
Polk |
Iowa |
Shannon Keely Moses |
Jessy James Dentler |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Aaron Snow |
rasnowremovals.inc@gmail.com |
President |
Altoona |
Polk |
Iowa |
Shannon Keely Moses |
Jessy James Dentler |
Signed |
356 |
2021-11-05 20:38 |
Anonymous (not verified) |
174.198.67.233 |
R.A. Snow Removals, Inc |
525 7th St. NW Altoona, IA 50009 |
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. |
2021-11-05 |
Robert Snow |
rasnowremovals.inc@gmail.com |
Altoona |
Polk |
Iowa |
Shannon Moses |
Jameson Snow |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Aaron Snow |
rasnowremovals.inc@gmail.com |
President |
Altoona |
Polk |
Iowa |
Shannon Moses |
Jameson Snow |
Signed |
523 |
2022-07-29 10:25 |
Anonymous (not verified) |
174.235.192.89 |
Jayden leinen |
5176 ne 88th st altoona 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. |
2022-07-29 |
Jayden leinen |
jman.legend@outlook.com |
Altoona |
Polk |
Iowa |
Kaden Barton |
Noah Penn |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jayden Leinen |
jman.legend@outlook.con |
President |
Altoona |
Polk |
Iowa |
Kaden Barton |
Noah Penn |
Signed |
576 |
2022-12-01 10:54 |
Anonymous (not verified) |
97.125.244.8 |
R A Snow Removals, Inc |
525 7th St NW, Altoona, IA 50009 |
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. |
2022-12-01 |
Robert Aaron Snow |
snowelectric22@gmail.com |
Altoona |
Polk |
Iowa |
Shannon Keely Moses |
Jameson Robert Snow |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Aaron Snow |
snowelectric22@gmail.com |
Owner |
Altoona |
Polk |
Iowa |
Shannon Keely Moses |
Jameson Robert Snow |
Signed |
598 |
2023-02-10 09:38 |
Anonymous (not verified) |
94.188.207.225 |
Y & M Cleaning Services Inc. |
4380 SE 15th Ct |
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. |
2023-02-10 |
Martine Martinez |
martinmtzmartinez@gmail.com |
Des Moines |
Polk |
Iowa |
Suzanne E Collier |
Andy Boyd |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Suzanne E Collier |
scollie1@amfam.com |
Non Related |
Altoona |
Polk |
IA |
Andy Boyd |
Martin Martinez |
Signed |
962 |
2024-04-26 08:46 |
Anonymous (not verified) |
94.188.207.225 |
Gilbert Construction |
3174 Hwy F48 West Newton, Iowa 50208 |
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. |
2024-04-26 |
Christian Gilbert |
christian.gilbert14@gmail.com |
Newton |
Jasper |
Iowa |
Leslie Gilbert |
Shane Gilbert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christian Gilbert |
christian.gilbert14@gmail.com |
worker |
Altoona |
polk |
iowa |
Leslie Gilbert |
Shane Gilbert |
Signed |
254 |
2021-05-04 17:25 |
Anonymous (not verified) |
208.38.228.16 |
NSENSE Incorporater |
415 Stanton Ave, Suite 205, Ames, IA 50014 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-04 |
Natalia Rogovska |
nrogovska@n-sense.us |
Ames |
Story |
Iowa |
Halyna Mudryk |
Petro Kyveryga |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Natalia Rogovska |
nrogovska@n-sense.us |
Vice-President |
Ames |
Story |
Iowa |
Halyna Mudryk |
Petro Kyveryga |
Signed |
255 |
2021-05-04 21:04 |
Anonymous (not verified) |
208.38.228.16 |
NSENSE Incorporated |
415 Stanton Ave, Suite 205, Ames, IA 50014 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-04 |
Natalia Rogovska |
nrogovska@n-sense.us |
Ames |
Story |
Iowa |
Petro Kyveryga |
Halyna Mudryk |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Natalia Rogovska |
nrogovska@n-sense.us |
Vice-President |
Ames |
Story |
Iowa |
Petro Kyveryga |
Halyna Mudryk |
Signed |
256 |
2021-05-05 08:04 |
Anonymous (not verified) |
206.127.178.33 |
NSense, Inc. |
415 Stanton Ave Suite 205, Ames, IA 50014 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-05 |
Stephen R Ringlee |
sringlee@n-sense.us |
Ames |
Story |
Iowa |
Constance J. Ringlee |
Robert Anders |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Stephen R Ringlee |
sringlee@n-sense.us |
Director |
Ames |
Story |
Iowa |
Constance J Ringlee |
Robert Anders |
Signed |
257 |
2021-05-05 14:36 |
Anonymous (not verified) |
208.38.228.41 |
NSENSE inc |
415 Stanton Ave. Suite 205 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-05 |
David A. Laird |
dalaird@n-sense.us |
Ames |
Story |
IA |
Raina Powell |
Josh Powell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Laird |
dalaird@n-sense.us |
President |
Ames |
Story |
IA |
Besta Pruski |
Marek Pruski |
Signed |
278 |
2021-06-18 11:37 |
Anonymous (not verified) |
75.162.29.203 |
Digital Agronomy, LLC |
4270 199th St. Ames, IA 50014 |
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. |
2021-06-17 |
Patrick T. Murphy |
ptmurphy82@gmail.com |
Ames |
Story |
Iowa |
David Cory |
Mary Cory |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Patrick T. Murphy |
ptmurphy82@gmail.com |
Owner |
Ames |
Story |
Iowa |
David Cory |
Mary Cory |
Signed |
297 |
2021-07-30 11:05 |
Anonymous (not verified) |
165.225.60.212 |
Love Tap Racing LLC |
1122 Sunset Ave, Kelley, IA 50134 |
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. |
2021-07-30 |
Timothy Love |
tiredemon@gmail.com |
Kelley |
Story |
IA |
Katie Frame |
Cody Jones |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Timothy Love |
tiredemon@gmail.com |
Owner |
Ames |
Story |
IA |
Katie Frame |
Cody Jones |
Signed |
298 |
2021-07-30 11:05 |
Anonymous (not verified) |
165.225.60.212 |
Love Tap Racing LLC |
1122 Sunset Ave, Kelley, IA 50134 |
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. |
2021-07-30 |
Laura Love |
tiredemon@gmail.com |
Kelley |
Story |
IA |
Katie Frame |
Cody Jones |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Laura Love |
tiredemon@gmail.com |
Owner |
Ames |
Story |
IA |
Katie Frame |
Cody Jones |
Signed |
368 |
2021-11-24 07:11 |
Anonymous (not verified) |
173.20.97.32 |
Neppl Landscape Architecture and Planning, LLC |
3013 Briggs Circle Ames, Iowa 50010 |
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. |
2021-11-24 |
Thomas George Neppl |
tom@tomneppl.com |
Ames |
Story |
Iowa |
Ashlyn Kay Neppl |
Tricia Kay Neppl |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Thomas George Neppl |
tom@tomneppl.com |
Owner |
Ames |
Story |
Iowa |
Ashlyn Kay Neppl |
Tricia Kay Neppl |
Signed |
378 |
2022-01-03 15:16 |
Anonymous (not verified) |
217.180.230.157 |
True360, Inc. |
1805 Collaboration Place, Suite 1300, Ames, Iowa 50010 |
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. |
2022-01-03 |
Christopher James |
chris@true-360.com |
Ames |
Iowa |
United States |
Jesse Kisker |
Cody Kapka |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christopher James |
chris@true-360.com |
President and Chief Executive Officer |
Ames |
Iowa |
United States |
Jesse Kisker |
Cody Kapka |
Signed |
532 |
2022-09-07 12:42 |
Anonymous (not verified) |
217.180.226.147 |
Practical Farmers of Iowa |
1615 Golden Aspen Dr., Suite 101, Ames, IA 50010 |
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. |
2022-09-07 |
Jonathan Bakehouse |
jon@mapleedgefarm.com |
Hastings |
Mills |
Iowa |
Jeanne-Marie Bakehouse |
DeWayne Kroledge |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sally Worley |
sally@practicalfarmers.org |
Executive Director |
Ames |
Story |
United States |
Jeann-Marie Bakehouse |
DeWayne Kroledge |
Signed |
564 |
2022-11-12 13:05 |
Anonymous (not verified) |
152.117.104.212 |
ArborSharp Tree Care LLC |
125 South Russell Ave Ames IA 50010 |
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. |
2022-11-12 |
Jonathan Michael Ostermann |
arborsharptc@gmail.com |
Ames |
IA |
IA |
Ben Wyatt |
Marc McClanahan |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jonathan Ostermann |
arborsharptc@gmail.com |
owner |
Ames |
story |
IA |
Ben Wyatt |
Marc McClanahan |
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 |
795 |
2023-10-18 14:29 |
Anonymous (not verified) |
94.188.205.169 |
Yarn Tree Designs Inc |
117 Alexander Ave, Ames, IA 50010 |
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. |
2023-10-18 |
Sarah Beth Johnson |
Beth@yarntree.com |
Ames |
Story |
Iowa |
Megan Chriswisser |
Erica Lenig |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Larry R Johnson |
larry@yarntree.com |
VP |
Ames |
Story |
Iowa |
Megan Chriswisser |
Erica Lenig |
Signed |
796 |
2023-10-18 14:34 |
Anonymous (not verified) |
94.188.205.177 |
Yarn Tree Designs Inc |
117 Alexander Ave, Ames, IA 50010 |
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. |
2023-10-18 |
Larry R Johnson |
larry@yarntree.com |
Ames |
Story |
Iowa |
Megan Chriswisser |
Erica Lenig |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Larry R Johnson |
larry@yarntree.com |
VP |
Ames |
Story |
Iowa |
Megan Chriswisser |
Erica Lenig |
Signed |
915 |
2024-03-08 13:24 |
Anonymous (not verified) |
94.188.205.174 |
One Call Exterior LLC |
1918 9th St Des Moines 50314 |
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 |
Nancy G Lopez |
onecallexteriors@gmail.com |
Des Moines |
Polk |
IA |
Monica Martinez |
Noe Ordaz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nancy G Lopez |
onecallexteriors@gmail.com |
Self |
Ames |
Story |
IA |
Monica Martinez |
Noe Ordaz |
Signed |
833 |
2023-12-12 07:31 |
Anonymous (not verified) |
94.188.207.224 |
Axe-cade LLC |
136 E Main Street Anamosa, IA 52205 |
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. |
2023-12-12 |
Teresa Coons |
axecadeonmain@gmail.com |
Anamosa |
Iowa |
United States |
Chad Coons |
Bret Funke |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chad Coons |
ccoons03@gmail.com |
Member |
Anamosa |
Iowa |
United States |
Teresa Coons |
Bret Funke |
Signed |
848 |
2024-01-05 13:05 |
Anonymous (not verified) |
94.188.205.177 |
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. |
2024-01-05 |
William J Feldmann |
feldmannwng@msn.com |
Anamosa |
Jones |
Iowa |
Bridget |
Camp |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William J Feldmann |
feldmannwng@msn.com |
Self |
Anamosa |
Jones |
Iowa |
Bridget |
Camp |
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 |
33 |
2020-01-15 10:31 |
Anonymous (not verified) |
216.161.118.103 |
ELOHIM HOME CARE AND STAFFING AGENCY, INC |
301 NE Trilein Dr , ste 4B, Ankeny IA 50021 |
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. |
2020-01-15 |
NITEZEHO NIYOMUGABO |
john@elohimhcs.com |
Ankeny |
Iowa |
United States |
john Tez |
Sem R |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John Tez |
john@elohimhcs.com |
Director |
Ankeny |
IA |
United States |
John Tez |
Tez |
Signed |
75 |
2020-04-29 11:07 |
Anonymous (not verified) |
107.77.206.22 |
ACR Construction, Inc |
7330 NW 21 St. Ankeny, IA 50023 |
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. |
2020-04-29 |
Andre Sean Drost |
andre.drost@acr-construction-inc.com |
Ankeny |
Polk |
IA |
Heidi Smith |
Jeff Smith |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Candace Drost |
acrdrost@hotmail.com |
President |
Ankeny |
Polk |
IA |
Heidi Smith |
Jeff Smith |
Signed |
79 |
2020-05-06 08:14 |
Anonymous (not verified) |
97.125.243.140 |
pro plumbing and heating llc |
903 nw 37th ct ankeny iowa 50023 |
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. |
2020-05-06 |
lee d kearney |
ankenypro@gmail.com |
ankeny |
polk |
iowa |
sheila m kearney |
keegan l kearney |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
lee d kearney |
ankenypro@gmail.com |
owner |
ankeny |
IA |
United States |
sheila m kearney |
keegan l kearney |
Signed |
85 |
2020-06-03 17:53 |
Anonymous (not verified) |
75.162.69.231 |
Blackford Foundations Inc |
501 SW Franklin Dr, Ankeny, IA 50023 |
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. |
2020-05-01 |
Brenda Marie Blackford |
brendab@blackfordfoundations.com |
Ankeny |
Polk |
Iowa |
Saree Luce |
Ricky Eatwell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brenda Marie Blackford |
brendab@blackfordfoundations.com |
President |
Ankeny |
Polk |
Iowa |
Saree Luce |
Ricky Eatwell |
Signed |
86 |
2020-06-03 17:56 |
Anonymous (not verified) |
75.162.69.231 |
Blackford Foundations Inc |
501 SW Franklin Dr, Ankeny, IA 50023 |
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. |
2020-05-01 |
Denny Lee Blackford |
blackfordfoundations@gmail.com |
Ankeny |
Polk |
Iowa |
Saree Luce |
Ricky Eatwell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Denny Lee Blackford |
blackfordfoundations@gmail.com |
Secretary |
Ankeny |
Polk |
Iowa |
Saree Luce |
Ricky Eatwell |
Signed |
151 |
2021-01-01 11:26 |
Anonymous (not verified) |
75.162.130.160 |
The Product Boss LLC |
20 Mountain Way, West Orange, NJ 07052 |
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. |
2021-01-01 |
Minna Khounlo-Sithep |
minna@theproductboss.com |
Ankeny |
IA |
IA |
Nalinh Sithep |
Suzzan Khounlo |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Minna Khounlo-Sithep |
minnaks@gmail.com |
Co-Owner |
Ankeny |
IA |
IA |
Nalinh Sithep |
Suzzan Khounlo |
Signed |
153 |
2021-01-06 13:20 |
Anonymous (not verified) |
167.142.147.6 |
PACIFIC DRYWALL CORPORATION |
105 SNYDER DRIVE HUXLEY, IOWA 50124 |
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. |
2021-01-06 |
JUAN JOSE AVALOS CASTELLANOS |
PACIFICDRYWALLCORP@GMAIL.COM |
ANKENY |
POLK |
IOWA |
JENNIFER LYNNE ESCOBAR |
LUIS MANUEAL AVALOS CASTELANOS |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
JUAN JOSE AVALOS CASTELLANOS |
PACIFICDRYWALLCORP@GMAIL.COM |
VICE PRESIDENT |
ANKENY |
POLKC |
IOWA |
JENNIFER LYNNE ESCOBAR |
LUIS MANUEL AVALOS CASTELANOS |
Signed |
307 |
2021-08-13 15:21 |
Anonymous (not verified) |
65.154.100.34 |
World of Reptiles Inc dba Snakes Alive |
3901 NW Seasons Ct Ankeny, IA 50023 |
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. |
2021-08-09 |
Ron Goodman |
ron_goo@msn.com |
Ankeny |
Polk |
IA |
Megan Matlock |
Tom Weidner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ron Goodman |
ron_goo@msn.com |
Owner |
Ankeny |
Polk |
IA |
Megan Matlock |
Tom Weidner |
Signed |
311 |
2021-08-16 12:25 |
Anonymous (not verified) |
65.154.100.34 |
World of Reptiles Inc dba Snakes Alive |
3901 NW Seasons Ct Ankeny, IA 50023 |
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. |
2021-08-09 |
Ron Goodman |
mmatlock@thedanaco.com |
Ankeny |
Polk |
IA |
Megan Matlock |
Tom Weidner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ron Goodman |
mmatlock@thedanaco.com |
Owner |
Ankeny |
Polk |
IA |
Megan Matlock |
Tom Weidner |
Signed |
357 |
2021-11-10 11:32 |
Anonymous (not verified) |
207.45.82.37 |
Green and Shine Services. INC |
210 Ne 41st ST APT 203 Ankeny, Iowa 50021 |
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. |
2021-11-10 |
Alex Adanel Lopez Redondo |
greenandshineservices@gmail.com |
Ankeny |
polk |
Iowa |
Marta Casado |
Giselle Roa Casado |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Alex ADANEL Lopez Redondo |
greenandshineservices@gmail.com |
owner |
Ankeny |
polk |
Iowa |
Marta Casado |
Giselle Roa Casado |
Signed |
394 |
2022-01-27 12:29 |
Anonymous (not verified) |
72.255.65.83 |
Rodgers’ Building & Remodeling Inc |
1003 NW 37th 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. |
2021-01-28 |
Benjamin Rodgers |
btrdsm18@gmail.com |
Ankeny |
Polk |
Iowa |
Mary Rodgers |
Larry Joel |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mary Rodgers |
steff.m2096@yahoo.com |
President |
Ankeny |
Polk |
Iowa |
Ben Rodgers |
Larry Joel |
Signed |
610 |
2023-02-23 16:19 |
Anonymous (not verified) |
94.188.207.228 |
Glorious tile service llc |
3905 NE 6th st Ankeny IA 50021 |
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. |
2023-02-23 |
Heileselaisi unguec |
glorioustile6@gmail.com |
Ankeny |
United States |
IOWA |
Robert duku |
Abraham deng |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Heileselaisi unguec |
glorioustile6@gmail.com |
Owner llc member |
Ankeny |
United States |
Iowa |
Robert duku |
Abraham deng |
Signed |
611 |
2023-02-23 16:27 |
Anonymous (not verified) |
94.188.207.224 |
Sandra unguec |
3905 NE 6th st Ankeny IA 50021 |
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. |
2023-02-23 |
Sandra unguec |
glorioustile6@gmail.com |
Ankeny |
United States |
Iowa |
Robert duku |
Abraham deng |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Sandra unguec |
glorioustile6@gmail.com |
Wife of the owner |
Ankeny |
United States |
Iowa |
Robert duku |
Abraham deng |
Signed |
655 |
2023-04-18 16:59 |
Anonymous (not verified) |
94.188.205.166 |
Next level tile and marble |
6918 NW 4th st Ankeny 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. |
2023-04-18 |
Jason John Henry Schneider |
jjhschneider@gmail.com |
Ankeny |
Polk |
Iowa |
Mario Demarco |
Jennifer Schneider |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jason Schneider |
jjhschneider@gmail.com |
Owner |
Ankeny |
Polk |
Iowa |
Mario Demarco |
Jennifer Schneider |
Signed |
662 |
2023-05-01 14:36 |
Anonymous (not verified) |
94.188.207.230 |
RH tile stone |
1403 Ne Falstaff ln |
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. |
2023-05-01 |
Raif Hadzic |
rh-tile@outlook.com |
Ankeny |
Polk |
Iowa |
Mario demarco |
Raif Hadzic |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Raif Hadzic |
rh-tile@outlook.com |
Sob contract |
Ankeny |
Polk |
Iowa |
Mario demarco |
Raif Hadzic |
Signed |
738 |
2023-08-11 08:47 |
Anonymous (not verified) |
94.188.207.223 |
Infrastructure Engineering, Inc. |
1451 NE 69TH PL, Ste 42 Ankeny, IA 50021 |
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. |
2023-08-11 |
Joel Peiffer |
peifferj@ieidsm.com |
Ankeny |
Polk |
Iowa |
Bret Larkins |
Heather Cornwell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joel Peiffer |
peifferj@ieidsm.com |
Owner |
ANKENY |
Iowa |
Iowa |
Bret Larkins |
Heather Cornwell |
Signed |
646 |
2023-03-31 13:58 |
Anonymous (not verified) |
94.188.205.168 |
American Residential Services Inc |
1683 Elizabeth Dr Marion IA 52302 |
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. |
2023-03-31 |
Robert Rettmann |
americanres@yahoo.com |
Apple Valley |
Dakota |
MN |
Nancy Rettmann |
William Dilts |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Rettmann |
americanres@yahoo.com |
President |
Apple Valley |
Dakota |
MN |
Nancy Rettmann |
William Dilts |
Signed |
480 |
2022-05-30 11:37 |
Anonymous (not verified) |
134.215.6.237 |
Access Property Management Corp DBA Wine & Spirits |
510 E Carrington Ln, Appleton, WI 54913 |
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. |
2022-05-30 |
Lisa M Ricklefs |
lisarick19@yahoo.com |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferek |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Thomas Ricklefs |
tjrick@yahoo.com |
President |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferak |
Signed |
481 |
2022-05-30 11:42 |
Anonymous (not verified) |
134.215.6.237 |
Access Property Management Corp DBA Wine & Spirits |
510 E Carrington Ln, Appleton, WI 54913 |
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. |
2022-05-30 |
Thomas J Ricklefs |
tjrick@yahoo.com |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferek |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa M Ricklefs |
lisarick19@yahoo.com |
VP |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferek |
Signed |
215 |
2021-03-29 07:58 |
Anonymous (not verified) |
173.18.193.51 |
Lee County Fair, Inc |
PO Box 179 |
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. |
2021-03-05 |
Dillon Benner |
judy@fullenkampins.com |
ARgyle |
IA |
United States |
Lindsey Lampe |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dillon Benner |
judy@fullenkampins.com |
Board Member |
Argyle |
IA |
United States |
Lindsey Lampe |
Judy Moeller |
Signed |
223 |
2021-03-29 08:11 |
Anonymous (not verified) |
173.18.193.51 |
Lee County Fair, Inc |
PO Box 179, Donnellson, 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. |
2021-03-04 |
Tammy LeMaster |
judy@fullenkampins.com |
Argyle |
Lee |
iowa |
Lindsey Lampe |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tammy LeMaster |
judy@fullenkampins.com |
Board Member |
ARgyle |
Lee |
Iowa |
Lindsey Lampe |
Judy Moeller |
Signed |
66 |
2020-04-20 13:41 |
Anonymous (not verified) |
173.24.181.211 |
Historic Arnolds Park Inc |
37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 |
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. |
2020-04-01 |
Tresa Hussong |
jennifer@walkerinsuranceia.com |
Arnolds Park |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tresa Hussong |
jennifer@walkerinsuranceia.com |
Board Member |
Arnolds Park |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
579 |
2022-12-07 14:37 |
Anonymous (not verified) |
96.31.1.206 |
IGL RENTAL LLC |
PO BOX 317 ARNOLDS PARK IA 51331 |
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. |
2022-10-25 |
CHAD JONES |
STAYBOJI@GMAIL.COM |
ARNOLDS PARK |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CHAD JONES |
STAYBOJI@GMAIL.COM |
MEMBER |
ARNOLDS PARK |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
461 |
2022-05-02 11:08 |
Anonymous (not verified) |
192.119.212.86 |
Iceberg Enterprises LLC |
101 E. 1st street Arthur IA 51431 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-02 |
Jesse Bergman |
jk_montana@yahoo.com |
arthur |
Iowa |
United States |
Maren Smith |
Darren Smith |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Katherine Bergman |
jk_montana@yahoo.com |
Owner |
Arthur |
IOWA |
United States |
Susan Bergman |
Jesse Bergman |
Signed |
375 |
2021-12-23 12:23 |
Anonymous (not verified) |
66.230.245.47 |
W. R. Elliot & Associates, Ltd. |
3306 Brook Hollow Dr, Asbury, IA 52002 |
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. |
2021-12-23 |
William R. Elliot |
bill@wreassoc.com |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L. Spalla |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William R. Elliot |
bill@wreassoc.com |
President |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L Spalla |
Signed |
376 |
2021-12-29 14:40 |
Anonymous (not verified) |
66.230.245.47 |
W. R. Elliot & Associates, Ltd. |
3306 Brook Hollow Dr, Asbury, IA 52002 |
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. |
2021-12-29 |
Karen R. Elliot |
karen@handiwerks.com |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L Spalla |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William R. Elliot |
bill@wreassoc.com |
President |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L Spalla |
Signed |
774 |
2023-09-21 10:21 |
Anonymous (not verified) |
94.188.205.167 |
Tri State Trucking LLC |
47282 US Hwy 20 Atkinson, NE 68713 |
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. |
2023-09-21 |
Casey Schaaf |
casey@tri-statetrucking.com |
Atkinson |
Holt |
NE |
Angela Schaaf |
Crystal Osborne |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Casey Schaaf |
casey@tri-statetrucking.com |
Owner |
Atkinson |
Holt |
NE |
Angela Schaaf |
Crystal Osborne |
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 |
247 |
2021-04-27 09:35 |
Anonymous (not verified) |
207.191.206.210 |
United windows and siding |
4080 1st Avenue NE, Cedar Rapids Iowa 52402 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2021-04-27 |
Adrian Sanchez |
adrian@unitedwindowsandsiding.com |
Aurora |
CO |
United States |
Megan Bierley |
Ginger Berens |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Adrian Sanchez |
adrian@unitedwindowsandsiding.com |
Owner |
Aurora |
Jeffereson |
CO |
Megan Bierley |
Ginger Berens |
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 |
714 |
2023-07-25 16:16 |
Anonymous (not verified) |
94.188.207.224 |
Midwest Systems |
2877 130th 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. |
2023-07-25 |
Matt Griswold |
midwestsystems@live.com |
Aurora |
IA |
United States |
Creatleigh Griswold |
Carslyn Griswold |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Matt Griswold |
midwestsystems@live.com |
Owner |
Aurora |
IA |
United States |
Creatleigh Griswold |
Carslyn Griswold |
Signed |
529 |
2022-09-01 13:53 |
Anonymous (not verified) |
72.131.73.148 |
Sozo Companies, Inc. |
23751 Hoover Road, Warren MI 48089 |
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. |
2022-09-01 |
Aaron Rasty |
arasty@sozocompanies.com |
Austin |
Travis |
Texas |
Robert Davis |
Paul Huth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Aaron Rasty |
arasty@sozocompanies.com |
President |
Austin |
Travis |
Texas |
Robert Davis |
Paul Huth |
Signed |
456 |
2022-04-29 08:14 |
Anonymous (not verified) |
107.126.24.57 |
Thatcher Auto Center INC |
406 S West Ave. Baxter, IA 50028 |
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. |
2022-01-01 |
Matthew Lee Wells |
Praynostop@msn.com |
Des Moines |
Polk |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rick Thatcher |
rickswrecks@gmail.com |
President |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
457 |
2022-04-29 08:21 |
Anonymous (not verified) |
107.126.24.57 |
Thatcher Auto Center INC |
406 S West ave Baxter, IA 50028 |
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. |
2022-01-01 |
Nathan Doubek |
thatcherautocenter@gmail.com |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rick Thatcher |
rickswrecks@gmail.com |
President |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
458 |
2022-04-29 08:26 |
Anonymous (not verified) |
107.126.24.57 |
Thatcher Auto Center INC |
406 S West ave Baxter Iowa 50028 |
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. |
2022-01-01 |
Richard Thatcher |
rickswrecks@gmail.com |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nathan Doubek |
thatcherautocenter@gmail.com |
Vice President |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
459 |
2022-04-29 08:49 |
Anonymous (not verified) |
107.126.24.57 |
Thatcher Auto Center INC |
406 S West ave Baxter. IA 50028 |
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. |
2022-02-15 |
David Kirkman |
kirkcola@gmail.com |
Newton |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rick Thatcher |
rickswrecks@gmail.com |
President |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
894 |
2024-02-23 08:17 |
Anonymous (not verified) |
94.188.207.226 |
MIDSTATE SOLUTION LLC |
107 Harrison Dr Baxter, IA 50028 |
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. |
2024-02-23 |
Kenneth Schlosser |
schlosser64@icloud.com |
Colfax |
Jasper |
IA |
Kinley Bethards |
Grant Alexander |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Justin Myers |
justinm@midstatesolution.com |
Owner |
Baxter |
Jasper |
IA |
Kinley Bethards |
Grant Alexander |
Signed |
765 |
2023-09-12 12:44 |
Anonymous (not verified) |
94.188.207.229 |
Southwest Sanitation Inc |
Clarinda, 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. |
2023-09-12 |
Lindsay A Schrock |
swsanitation@gmail.com |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lindsay Schrock |
swsanitation@gmail.com |
Treasure |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
766 |
2023-09-12 12:46 |
Anonymous (not verified) |
94.188.207.224 |
Southwest Sanitation |
Clarinda, 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. |
2023-09-12 |
Craig Schrock |
swsanitation@gmail.com |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lindsay Schrock |
swsanitation@gmail.com |
Treasure |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
767 |
2023-09-12 12:48 |
Anonymous (not verified) |
94.188.207.223 |
Southwest Sanitation |
Clarinda, 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. |
2023-09-12 |
Lonnie Weed |
swsanitation@gmail.com |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lindsay Schrock |
swsanitation@gmail.com |
Treasure |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
769 |
2023-09-12 12:49 |
Anonymous (not verified) |
94.188.207.223 |
Southwest Sanitation |
Clarinda, 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. |
2023-09-12 |
Joshua Weed |
swsanitation@gmail.com |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lindsay Schrock |
swsanitation@gmail.com |
Treasure |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
231 |
2021-04-11 12:19 |
Anonymous (not verified) |
174.243.115.140 |
Blaser Plumbing Inc |
28933 Sieverding Ridge Rd Bellevue IA 52031 |
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. |
2021-04-11 |
Michael Blaser |
bpi1999@hotmail.com |
Bellevue |
IA |
United States |
Joyce Langmeier |
Sylvester Langmeier |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Blaser |
bpi1999@hotmail.com |
Owner |
Bellevue |
IA |
United States |
Joyce Langmeier |
Sylvester Langmeier |
Signed |
585 |
2022-12-15 20:32 |
Anonymous (not verified) |
192.110.196.132 |
Maywood Enterprises, Inc. |
28345 Highway 52, Bellevue, IA 52031 |
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. |
2022-12-15 |
Ann L Wachtel |
annw@financepro123.com |
Bellevue |
Jackson |
Iowa |
Katie Laban |
Jeffrey Laban |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ann L Wachtel |
annw@financepro123.com |
President |
Bellevue |
Jackson |
IA |
Katie Laban |
Jeffrey Laban |
Signed |
645 |
2023-03-31 08:55 |
Anonymous (not verified) |
94.188.205.166 |
3Fitt Life, Inc. |
28345 Highway 52, Bellevue, IA 52031 |
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. |
2023-03-31 |
Ann L Wachtel |
annw@3fitt.com |
Bellevue |
Jackson |
Iowa |
Jeff Laban |
Katie Laban |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ann L Wachtel |
annw@3fitt.com |
President |
Bellevue |
Jackson |
Iowa |
Jeff Laban |
Katie Laban |
Signed |
160 |
2021-01-13 10:52 |
Anonymous (not verified) |
173.190.64.239 |
united workers inc |
711 4th st ne |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-13 |
mayra sapolvada |
buck@trvnet.net |
Belmond |
wright |
iowa |
shannon muhlenbruch |
Martha Leal |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
mayra sapulvada |
buck@trvnet.net |
president |
belmond |
wright |
ia |
shannon myhlenbruch |
martha leal |
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 |
586 |
2022-12-16 15:53 |
Anonymous (not verified) |
184.184.197.146 |
Halide Biologics |
330 Golfview Ave, Iowa City IA 52246 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-12-15 |
Daniel Infield |
danielinfield@gmil.com |
Bennington |
Douglas |
Nebraska |
Alexander Estell |
Jesse Herrera |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Infield |
danielinfield@gmail.com |
President |
Bennington |
NE |
United States |
Alexander Estell |
Jesse Herrera |
Signed |
839 |
2023-12-18 16:12 |
Anonymous (not verified) |
94.188.207.227 |
515 Painting llc |
po box 157 |
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. |
2023-12-18 |
Marvin S Parker JR |
stvpkr@gmail.com |
berwick |
polk |
iowa |
Christopher Eldridge |
Dillon Parker |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Marvin parker |
stvpkr@gmail.com |
owner |
berwick |
Polk |
Iowa |
Christopher Eldridge |
Dillon Parker |
Signed |
59 |
2020-04-14 12:54 |
Anonymous (not verified) |
65.126.161.162 |
Elite Carpentry |
1515 21st Street Bettendorf, IA 52722 |
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. |
2020-04-10 |
Jeffrey D. Leech |
elitecarpentryqc@gmail.com |
Bettendorf |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Jeffrey D. Leech |
elitecarpentryqc@gmail.com |
President |
Bettendorf |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
95 |
2020-07-02 10:30 |
Anonymous (not verified) |
206.125.132.254 |
Dave Prochaska Construction |
5848 Hopeview Ct |
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. |
2020-07-02 |
Dave Prochaska |
kschepers@nelsonbrothersagency.com |
Bettendorf |
Scott |
IA |
Kaitlin Schepers |
Lori Fisher |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dave Prochaska |
kschepers@nelsonbrothersagency.com |
Owner |
Bettendorf |
Scott |
IA |
Kaitlin Schepers |
Lori Fisher |
Signed |
148 |
2020-12-30 08:22 |
Anonymous (not verified) |
166.181.83.201 |
Elite Carpentry |
P.O. Box 1162 Bettendorf Iowa 52722 |
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. |
2020-12-30 |
Jeffrey D Leech |
Elitecarpentryqc@gmail.com |
Bettendorf |
Scott |
Iowa |
Jeremy Havens |
Michael Rodriguez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffrey D Leech |
Elitecarpentryqc@gmail.com |
Owner |
Bettendorf |
Scott |
Iowa |
Jeremy Havens |
Michael Rodriguez |
Signed |
709 |
2023-07-17 15:46 |
Anonymous (not verified) |
94.188.205.166 |
Breuer Roofing Company |
3021 Sunburst Dr. Bettendorf, IA 52722 |
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. |
2023-07-17 |
Chad Breuer |
chadbreuer@gmail.com |
Bettendorf |
Scott |
IA |
Caroline Kristina Breuer |
Patricia Ann Breuer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chad Michael Breuer |
chadbreuer@gmail.com |
President |
Bettendorf |
Scott |
IA |
Caroline Kristina Breuer |
Patricia Ann Breuer |
Signed |
712 |
2023-07-24 12:34 |
Anonymous (not verified) |
94.188.205.168 |
BOG Roofing |
3768 Deerbrook 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. |
(1) I reject the employers’ liability coverage. |
2023-07-24 |
Devon Booton |
devonboot1973@gmail.com |
Bettendorf |
Iowa |
United States |
Viviana Gonzalez |
Shannon Wolever |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Devon Booton |
devonboot1973@gmail.com |
Self |
Bettendorf |
Iowa |
United States |
Viviana Gonzalez |
Shannon Wolever |
Signed |
740 |
2023-08-14 10:25 |
Anonymous (not verified) |
94.188.205.167 |
Absolute Mud Jacking Inc |
5038 Brittany Ct Bettendorf Iowa 52722 |
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. |
2023-08-12 |
Paul Pelzer |
pelzer830@gmail.com |
Bettendorf |
IA |
United States |
Brett Lewandowski |
Phil Schaefer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Pelzer |
pelzer830@gmail.com |
Owner |
Bettendorf |
IA |
United States |
Brett Lewandowski |
Phil Schaefer |
Signed |
908 |
2024-03-02 14:33 |
Anonymous (not verified) |
94.188.207.230 |
Gerlich Enterprises |
2824 Hickory Hills Ln |
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. |
2024-03-02 |
Paul Gerlich |
paul@gerlich.io |
Bettendorf |
scott |
IA |
Kelsey Gerlich |
Elora Gerlich |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Gerlich |
paul@gelrich.io |
Owner |
Bettendorf |
Scott |
Iowa |
Kelsey Gerlich |
Garrett Gerlich |
Signed |
909 |
2024-03-02 14:33 |
Anonymous (not verified) |
94.188.207.224 |
Gerlich Enterprises |
2824 Hickory Hills Ln |
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. |
2024-03-02 |
Kelsey Gerlich |
paul@gerlich.io |
Bettendorf |
scott |
IA |
Paul Gerlich |
Elora Gerlich |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Gerlich |
paul@gelrich.io |
Owner |
Bettendorf |
Scott |
Iowa |
Elora Gerlich |
Garrett Gerlich |
Signed |
910 |
2024-03-02 14:34 |
Anonymous (not verified) |
94.188.207.224 |
Gerlich Enterprises |
2824 Hickory Hills Ln |
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. |
2024-03-02 |
Elora Gerlich |
paul@gerlich.io |
Bettendorf |
scott |
IA |
Paul Gerlich |
Kelsey Gerlich |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Gerlich |
paul@gelrich.io |
Owner |
Bettendorf |
Scott |
Iowa |
Kelsey Gerlich |
Garrett Gerlich |
Signed |
911 |
2024-03-02 14:34 |
Anonymous (not verified) |
94.188.205.168 |
Gerlich Enterprises |
2824 Hickory Hills Ln |
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. |
2024-03-02 |
Garrett Gerlich |
paul@gerlich.io |
Bettendorf |
scott |
IA |
Paul Gerlich |
Kelsey Gerlich |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Gerlich |
paul@gelrich.io |
Owner |
Bettendorf |
Scott |
Iowa |
Kelsey Gerlich |
Elora Gerlich |
Signed |
952 |
2024-04-08 17:25 |
Anonymous (not verified) |
94.188.205.175 |
Bio-Inspired Design Aeronautics Corp |
6843 Still Creek Pass |
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 |
Joseph Mitchell |
aerotech@hush.com |
Bettendorf |
Iowa |
United States |
Mike Owens |
Chris DeCock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Hollie Mitchell |
mitchhollie@yahoo.com |
Vice President |
Bettendorf |
Iowa |
United States |
Mike Owens |
Chris DeCock |
Signed |