93 |
2020-06-30 13:48 |
Anonymous (not verified) |
50.82.87.122 |
Waterfall Design LLC |
3184 Berkshire Pkwy Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-01-01 |
John Lanscak III |
waterfalldesign3@gmail.com |
Clive |
Iowa |
United States |
Josh Fisk |
Tom Childes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John Lanscak III |
waterfalldesign3@gmail.com |
owner/CEO |
Clive |
Iowa |
United States |
Josh Fisk |
Tom Childes |
Signed |
92 |
2020-06-30 13:46 |
Anonymous (not verified) |
50.82.87.122 |
Diamond Bath LLC |
3184 Berkshire Pkwy Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-01-01 |
Patricia Fisk |
diamondbathllc@gmail.com |
Clive |
Iowa |
United States |
Josh Fisk |
Tom Childes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Patricia Fisk |
diamondbathllc@gmail.com |
Owner/CEO |
Clive |
Iowa |
United States |
Josh Fisk |
Tom Childes |
Signed |
91 |
2020-06-17 17:47 |
Anonymous (not verified) |
166.182.83.28 |
BJJ Painting Inc |
6940 Rolling Ridge CT 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. |
2020-06-17 |
Bradley Johnson |
brad.johnson@fivestarpainting.com |
Cedar Rapids |
Linn |
Iowa |
Mike McClure |
Tony Gaiffe |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradley Johnson |
brad.johnson@fivestarpainting.com |
President |
Cedar Rapids |
Linn |
Iowa |
Mike McClure |
Tony Gaiffe |
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 |
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 |
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 |
87 |
2020-06-09 14:49 |
Anonymous (not verified) |
185.169.109.170 |
Sweeney Builders Inc |
511 8th Ave NW |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-06-09 |
Michael Lee Sweeney |
mike@sweeneybuilders.com |
Waukon |
Allamakee |
Iowa |
Shawna Sweeney |
Jean Gavin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Shawna Sweeney |
shawna@sweeneybuilders.com |
Vice President |
Waukon |
Allamakee |
IA |
Mike Sweeney |
Jean Gavin |
Signed |
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 |
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 |
84 |
2020-06-01 16:31 |
Anonymous (not verified) |
173.29.126.110 |
TruthPoint Media LLC |
1945 Andrews Drive, Pleasant Hill, IA 50327 |
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. |
2020-06-01 |
Robert Lee Moore |
robb@truthpointmedia.com |
Pleasant Hill |
Polk |
Iowa |
Self, Sole Proprietor and LLC Member, TruthPoint Media LLC |
Self, Sole Proprietor and LLC Member, TruthPoint Media LLC |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert L Moore |
robb@truthpointmedia.com |
Self |
Pleasant Hill |
Polk |
Iowa |
Self, Sole Proprietor and LLC Member, TruthPoint Media LLC |
Self, Sole Proprietor and LLC Member, TruthPoint Media LLC |
Signed |
83 |
2020-05-20 12:34 |
Anonymous (not verified) |
108.171.131.188 |
North Iowa Custom Seamless Guttering, Inc |
PO Box 512, 1300 2nd Ave S, Clear Lake, Iowa 50428 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-05-20 |
Keith E Main |
keithmaincsg@hotmail.com |
Clear Lake |
Cerro Gordo |
Iowa |
Lloyd L Heinselman |
Diane K Harrington |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Keith E Main |
keithmaincsg@hotmail.com |
President |
Clear Lake |
Cerro Gordo |
Iowa |
Lloyd L Heinselman |
Diane K Harrington |
Signed |
82 |
2020-05-18 15:16 |
Anonymous (not verified) |
184.80.177.137 |
Farmers Best Popcorn, LLC |
110 1st Street North, - Worthington, IA 52078 |
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. |
2020-05-18 |
Jon Ramaekers |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
self |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
81 |
2020-05-11 16:10 |
Anonymous (not verified) |
97.125.253.184 |
Rundle Creations L.L.C. |
5816 Urbandale Avenue, Des Moines, IA 50322 |
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. |
2020-05-11 |
Mark Lavern Rundle II |
rundlecreations@gmail.com |
Des Moines |
Polk |
Iowa |
Luis Alex Jimenez |
Jennifer Lea Griffith |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erika Anne Rundle |
rundlecreations@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Luis Alex Jimenez |
Jennifer Lea Griffith |
Signed |
80 |
2020-05-11 12:29 |
Anonymous (not verified) |
173.191.207.202 |
J&D Furniture-Land Corp |
144 1st Ave East - Dyersville, IA 52040 |
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. |
2020-05-07 |
Scott Hittenmiller |
dparsons@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
agent-English Insurance |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
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 |
78 |
2020-05-05 16:49 |
Anonymous (not verified) |
173.21.16.121 |
Kevan Oliver Trim Carpentry, Inc. |
2900 Scott Park Road, Eldridge, IA 52748 |
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. |
2020-05-05 |
Scarlett Oliver |
scarlettioliver@gmail.com |
Eldridge |
Scott |
Iowa |
Franco Muñoz |
Rolando Muñoz |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Kevan Oliver |
kkoliverinc@gmail.com |
President |
Eldridge |
Scott |
Iowa |
Franco Muñoz |
Rolando Muñoz |
Signed |
77 |
2020-05-05 16:47 |
Anonymous (not verified) |
173.21.16.121 |
Kevan Oliver Trim Carpentry, Inc. |
2900 Scott Park Road, Eldridge, IA 52748 |
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. |
2020-05-05 |
Kevan Oliver |
kkoliverinc@gmail.com |
Eldridge |
Scott |
Iowa |
Franco Muñoz |
Rolando Muñoz |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Kevan Oliver |
kkoliverinc@gmail.com |
President |
Eldridge |
Scott |
Iowa |
Franco Muñoz |
Rolando Muñoz |
Signed |
76 |
2020-05-04 10:24 |
Anonymous (not verified) |
173.191.207.202 |
Tim Fitzgerald Mechanical Services, Inc. |
724 1st Ave W - Dyersville, IA 52040 |
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. |
2020-04-24 |
Tim Fitzgerald |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
agent-English Insurance |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
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 |
74 |
2020-04-29 05:29 |
Anonymous (not verified) |
198.14.245.254 |
Clanton Creek Land Improvement |
2094 Pheasant Run Trail Peru Iowa 50222 |
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. |
2020-04-28 |
Spencer Minnich |
sminnich85@hotmail.com |
Peru |
Madison |
Iowa |
Sarah Minnich |
Travis Tuttle |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Spencer Minnich |
sminnich85@hotmail.com |
Vice President |
Peru |
Madison |
Iowa |
Sarah Minnich |
Travis Tuttle |
Signed |
73 |
2020-04-28 22:27 |
Anonymous (not verified) |
72.25.27.81 |
Clanton Creek Land Improvement |
3094 Pheasant Run Trail Peru, IA 50222 |
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. |
2020-04-28 |
Travis James Tuttle |
t.tuttle1982@gmail.com |
Peru |
Madison |
Iowa |
Sabrina Elaine Tuttle |
Spencer Gregory Minnich |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Travis James tuttle |
t.tuttle1982@gmail.com |
President |
Peru |
Madison |
Iowa |
Sabrina Elaine Tuttle |
Spencer Gregory Minnich |
Signed |
72 |
2020-04-27 16:24 |
Anonymous (not verified) |
140.82.166.162 |
Loss Control Specialist Inc |
1409 Jackson Woods Ct NW Cedar Rapids, IA 52409 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-28 |
Pamala Riggert |
jim@losscontrolspecialist.com |
Cedar Rapids |
Linn |
Iowa |
Megan Thomas |
Jessica Droppert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Pamala Riggert |
jim@losscontrolspecialist.com |
Secretary |
Cedar Rapids |
Linn |
Iowa |
Megan Thomas |
Jessica Droppert |
Signed |
71 |
2020-04-27 16:23 |
Anonymous (not verified) |
140.82.166.162 |
Loss Control Specialist Inc |
1409 Jackson Woods Ct NW Cedar Rapids, IA 52409 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-28 |
James Riggert |
jim@losscontrolspecialist.com |
Cedar Rapids |
Linn |
Iowa |
Megan Thomas |
Jessica Droppert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Riggert |
jim@losscontrolspecialist.com |
President |
Cedar Rapids |
Linn |
Iowa |
Megan Thomas |
Jessica Droppert |
Signed |
70 |
2020-04-21 10:29 |
Anonymous (not verified) |
173.24.181.211 |
Mr. Drain Man LLC |
607 36th Street, Spirit Lake IA 51360 |
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. |
2020-04-21 |
Jan Coon |
jennifer@walkerinsuranceia.com |
Spirit Lake |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mr Drain Man LLC |
jennifer@walkerinsuranceia.com |
Member |
Spirit Lake |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
69 |
2020-04-21 10:18 |
Anonymous (not verified) |
65.126.161.162 |
Mike Foster DBA Mike's Home Improvement |
2377 W 49th Street Davenport, IA 52806 |
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. |
2020-04-21 |
Michael A Foster Jr. |
None@none.com |
Davenport |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael A Foster Jr. |
None@none.com |
Owner |
Davenport |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
68 |
2020-04-20 13:50 |
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 |
Jill Harms |
jennifer@walkerinsuranceia.com |
Milford |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jill Harms |
jennifer@walkerinsuranceia.com |
President |
Milford |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
67 |
2020-04-20 13:46 |
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 |
John Franken |
jennifer@walkerinsuranceia.com |
Spirit Lake |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John Franken |
jennifer@walkerinsuranceia.com |
Vice President |
Spirit Lake |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
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 |
65 |
2020-04-20 13:37 |
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 |
Denny Walker |
jennifer@walkerinsuranceia.com |
West Okoboji |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Denny Walker |
jennifer@walkerinsuranceia.com |
Board Member |
West Okoboji |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
64 |
2020-04-20 13:30 |
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 |
Mike Bennett |
jennifer@walkerinsuranceia.com |
Jefferson |
Union |
South Dakota |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mike Bennett |
jennifer@walkerinsuranceia.com |
Treasurer |
Jefferson |
Union |
South Dakota |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
63 |
2020-04-20 13:23 |
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 |
Suzie Wilmot |
jennifer@walkerinsuranceia.com |
Minneapolis |
Hennepin |
Minnesota |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Suzie Wilmot |
jennifer@walkerinsuranceia.com |
Board Member |
Minneapolis |
Hennepin |
Minnesota |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
62 |
2020-04-20 13:18 |
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 |
Ron Morocco |
jennifer@walkerinsuranceia.com |
Milford |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ron Morocco |
jennifer@walkerinsuranceia.com |
Board Member |
Milford |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
61 |
2020-04-20 13:13 |
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 |
Bruce Tamisiea |
jennifer@walkerinsuranceia.com |
Wahpeton |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bruce Tamisiea |
jennifer@walkerinsuranceia.com |
Board Member |
Wahpeton |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
60 |
2020-04-20 13:06 |
Anonymous (not verified) |
173.24.181.211 |
Historic Arnolds Park Inc |
37 Lake Street, PO 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 |
Charley Whittenburg |
jennifer@walkerinsuranceia.com |
Spencer |
Clay |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Charley Whittenburg |
jennifer@walkerinsuranceia.com |
Vice President |
Spencer |
Clay |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
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 |
58 |
2020-04-14 08:32 |
Anonymous (not verified) |
174.217.17.57 |
Society of St Vincent de Paul, District Counsel Waterloo Iowa |
320 Broadway St PO Box 2727 Waterloo IA 50704 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-14 |
Rodney Crowe |
crorod@aol.com |
Waterloo |
Blackhawk |
Iowa |
George W Karnivk |
Glynis R Worthington |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph D Sobczyk |
joczyk@aol.com |
Corporate Treasurer |
Cdear Falls |
Blackhawk |
Iowa |
George W Karnick |
Glynis R Worthington |
Signed |
57 |
2020-04-10 11:14 |
Anonymous (not verified) |
136.34.78.83 |
KALONA SALES BARN, INC. |
191 9TH STREET; KALONA, IA 52247 |
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. |
2020-04-07 |
DEVIN MULLET |
LMULLET@KALONASALESBARN.COM |
KALONA |
WASHINGTON |
IOWA |
ALANA MULLET |
ROCHELLE MULLET |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
DEVIN MULLET |
LMULLET@KALONASALESBARN.COM |
OWNER |
KALONA |
WASHINGTON |
IOWA |
ALANA MULLET |
ROCHELLE MULLET |
Signed |
56 |
2020-04-10 11:12 |
Anonymous (not verified) |
136.34.78.83 |
KALONA SALES BARN, INC. |
121 9TH ST; KALONA, IA 52247 |
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 |
LAVAUGHN MULLET |
LMULLET@KALONASALESBARN.COM |
KALONA |
WASHINGTON |
IOWA |
ALANA MULLET |
ROCHELLE MULLET |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LAVAUGHN MULLET |
LMULLET@KALONASALESBARN.COM |
OWNER |
KALONA |
WASHINGTON |
IOWA |
ALANA MULLET |
ROCHELLE MULLET |
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 |
54 |
2020-04-03 19:30 |
Anonymous (not verified) |
173.25.134.162 |
Luke Laxton |
1502 guthrie 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. |
2020-04-03 |
Luke Laxton |
kyekingstonl@gmail.com |
Des Moines |
Iowa |
United States |
Omer Okic |
Nicholas weber |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Luke Laxton |
kyekingstonl@gmail.com |
Owner |
Des Moines |
Iowa |
United States |
Omer Okic |
Nicholas weber |
Signed |
53 |
2020-03-30 11:09 |
Anonymous (not verified) |
45.42.5.219 |
Taylor's Tri-State Construction |
660 Tanzanite Drive, Dubuque, IA 52001 |
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. |
2020-03-06 |
John Taylor |
taylorsconstruction78@yahoo.com |
Dubuque |
Dubuque |
Iowa |
Brenda Lewis |
Jessica Stepp |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John Taylor |
taylorsconstruction78@yahoo.com |
Co-owners |
Dubuque |
Dubuque |
Iowa |
Brenda Lewis |
Jessica Stepp |
Signed |
52 |
2020-03-30 11:04 |
Anonymous (not verified) |
45.42.5.219 |
Iowa Roofpros |
104 Anderson Street, Maquoketa, IA 52060 |
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. |
2020-03-17 |
Jamison Nienke |
iowaroofguru@gmail.com |
Maquoketa |
Jackson |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jamison Nienke |
iowaroofguru@gmail.com |
Co-owners |
Maquoketa |
Jackson |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
51 |
2020-03-30 11:01 |
Anonymous (not verified) |
45.42.5.219 |
Iowa Roofpros |
104 Anderson Street, Maquoketa, IA 52060 |
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. |
2020-03-17 |
Heather Nienke |
heather@nienkesolar.com |
Maquoketa |
Jackson |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Heather Nienke |
heather@nienkesolar.com |
Co-owners |
Maquoketa |
Jackson |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
50 |
2020-03-18 10:06 |
Anonymous (not verified) |
67.22.192.111 |
Rozeboom Trucking Inc. |
PO Box 110 Sioux Center IA 51250 |
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. |
2020-03-18 |
Kraig Hulstein |
kraigh@barkcattle.com |
Sioux Center |
Sioux |
Iowa |
Linda Kieft |
Tiffany Govig |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kirk Hulstein |
kirkh@barkcattle.com |
president |
Sioux Center |
Sioux |
Iowa |
Linda Kieft |
Tiffany Govig |
Signed |
49 |
2020-03-18 10:03 |
Anonymous (not verified) |
67.22.192.111 |
Rozeboom Trucking Inc. |
PO Box 110 Sioux Center IA 51250 |
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. |
2020-03-18 |
Kelly Hulstein |
kellyh@barkcattle.com |
Sioux Center |
Sioux |
Iowa |
Linda Kieft |
Tiffany Govig |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kirk Hulstein |
kirkh@barkcattle.com |
president |
Sioux Center |
Sioux |
Iowa |
Linda Kieft |
Tiffany Govig |
Signed |
48 |
2020-03-18 09:58 |
Anonymous (not verified) |
67.22.192.111 |
Rozeboom Trucking Inc. |
PO Box 110 Sioux Center IA 51250 |
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. |
2020-03-18 |
Kirk Hulstein |
kirkh@barkcattle.com |
Sioux Center |
Sioux |
Iowa |
Linda Kieft |
Tiffany Govig |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kirk Hulstein |
kirkh@barkcattle.com |
president |
Sioux Center |
Sioux |
Iowa |
Linda Kieft |
Tiffany Govig |
Signed |
47 |
2020-03-10 15:16 |
Anonymous (not verified) |
65.126.161.162 |
Advantage Customer Remodeling LLC |
3236 W 17th Street Davenport, IA 52804 |
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. |
2020-03-10 |
Tamethia Mitchell |
None@none.com |
Davenport |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tamethia Mitchell |
None@none.com |
Owner |
Davenport |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
46 |
2020-03-10 10:26 |
Anonymous (not verified) |
204.141.214.180 |
Shamrock Screenprinting Inc |
2710 Granite Ct NE |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-03-10 |
David Handley |
davehandley53@gmail.com |
Cedar Rapids |
Linn |
IA |
Lori Handley |
Beth Barta |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lori Handley |
Lori.handley@aol.com |
VP |
Cedar Rapids |
Linn |
IA |
Lori Handley |
Beth Barta |
Signed |
45 |
2020-03-10 10:24 |
Anonymous (not verified) |
204.141.214.180 |
Shamrock Screenprinting Inc |
2710 Granite Ct NE |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-03-10 |
Lori Handley |
lori.handley@aol.com |
Cedar Rapids |
Linn |
IA |
David Handley |
Beth Barta |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lori Handley |
lori.handley@aol.com |
VP |
Cedar Rapids |
Linn |
IA |
David Handley |
Beth Barta |
Signed |
44 |
2020-03-09 10:51 |
Anonymous (not verified) |
184.63.116.185 |
STURCO BUILDERS |
24472 15TH AVE NEW VIRGINIA IA 50210 |
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. |
2020-03-09 |
LANE WILLIAM STURTZ |
Sturcobuilders@live.com |
New virginia |
warren |
Iowa |
EMILY LAURA STURTZ |
JODI LEEANN GARNER |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LANE WILLIAM STURTZ |
Sturcobuilders@live.com |
OWNER |
NEW VIRGINIA |
WARREN |
IOWA |
EMILY LAURA STURTZ |
JODI LEEANN GARNER |
Signed |
43 |
2020-02-28 09:50 |
Anonymous (not verified) |
173.24.140.77 |
W R Main Contractor Inc |
1620 NW 78th Street, Clive, IA 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-28 |
Cindy Jo Ohmart |
co4mainco@aol.com |
West Des Moines |
Polk |
Iowa |
Jill Ann Reber |
Alane Marguerite Richardson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mark I Main |
markmain@icloud.com |
President |
Waukee |
Dallas |
Iowa |
Jill Ann Reber |
Alane Marguerite Richardson |
Signed |
42 |
2020-02-16 19:13 |
Anonymous (not verified) |
207.199.193.217 |
S J Hernandez, Inc |
19738 133rd Street Bloomfield, IA 52537 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-16 |
Salvador Hernandez-Perez |
jessieatcjs@gmail.com |
Bloomfield |
Davis |
Iowa |
Jessica Hernandez |
Joseph Olinger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Salvador Hernandez-Perez |
jessieatcjs@gmail.com |
Owner |
Bloomfield |
Davis |
Iowa |
Jessica Hernandez |
Joseph Olinger |
Signed |
41 |
2020-02-16 19:09 |
Anonymous (not verified) |
207.199.193.217 |
S J Hernandez, Inc |
19738 133rd Street Bloomfield, IA 52537 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-16 |
Jessica Hernandez |
jessieatcjs@gmail.com |
Bloomfield |
Davis |
Iowa |
Salvador Hernandez-Perez |
Joseph Olinger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jessica Hernandez |
jessieatcjs@gmail.com |
Owner |
Bloomfield |
Davis |
Iowa |
Salvador Hernandez-Perez |
Joseph Olinger |
Signed |
40 |
2020-02-14 09:22 |
Anonymous (not verified) |
50.83.38.221 |
Pa's Construction LLC |
2350 Glass RD NE |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-14 |
Daniel Saunders |
dan2112411@yahoo.com |
Cedar Rapids |
USA_IA |
USA_IA |
Walt Cheney |
Becky Cheney |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Saunders |
dan2112411@yahoo.com |
Owner- Manager |
Cedar Rapids |
USA_IA |
USA_IA |
Walt Cheney |
Becky Cheney |
Signed |
39 |
2020-02-10 16:37 |
Anonymous (not verified) |
67.212.103.193 |
Voelker Property Management, LLC |
1705 Quail Run Lane, Cedar Falls, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-10 |
Craig D Voelker |
cvoelker@cfu.net |
Cedar Falls |
Black Hawk |
Iowa |
Craig DVoelker |
Nikki D Voelker |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Craig D Voelker |
cvoelker@cfu.net |
Owner |
Cedar Falls |
Black Hawk |
Iowa |
Craig D Voelker |
Nikki D Voelker |
Signed |
38 |
2020-02-08 13:16 |
Anonymous (not verified) |
208.126.52.97 |
Savage Industries Inc |
2368 110th street Delmar, ia 52037 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-08 |
Jordan Hicks |
jjjhicks22@gmail.com |
Delmar |
Clinton |
Iowa |
Brittany Hicks |
Alex Laban |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jordan Hicks |
jjjhicks22@gmail.com |
President |
Delmar |
Clinton |
Iowa |
Brittany Hicks |
Alex Laban |
Signed |
37 |
2020-02-06 15:49 |
Anonymous (not verified) |
100.42.95.100 |
Matthew Saboe |
2075 330th St, Spencer IA 51301 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-06 |
Matthew Saboe |
galmgirl@gmail.com |
Spencer |
Clay |
IA |
Laura Ashley Tauscher |
Diane Kimball |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Matthew Saboe |
galmgirl@gmail.com |
Owner |
Spencer |
Clay |
IA |
Laura Ashley Tauscher |
Diane Kimball |
Signed |
36 |
2020-01-31 14:59 |
Anonymous (not verified) |
96.31.22.239 |
HOGMILE PORK LLC |
2032 220TH ST INWOOD IOWA 51240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-01-31 |
GLENN VANDEVEGTE |
glenvv@alliancecom.net |
INWOOD |
LYON |
IOWA |
LISA FABER |
ERIC TEGROOTENHUIS |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
GLENN VANDEVEGTE |
glennvv@alliancecom.net |
self |
INWOOD |
LYON |
IOWA |
LISA FABER |
ERIC TEGROOTENHUIS |
Signed |
35 |
2020-01-31 14:56 |
Anonymous (not verified) |
96.31.22.239 |
HOGMILE PORK LLC |
2032 220TH ST INWOOD, IOWA 51240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-01-31 |
GALEN VANDEVEGTE |
galenvv@alliancecom.net |
INWOOD |
LYON |
IOWA |
LISA FABER |
ERIC TEGROOTENHUIS |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
GALEN VANDEVEGTE |
galenvv@alliancecom.net |
SELF |
INWOOD |
LYON |
IOWA |
LISA FABER |
ERIC TEGROOTENHUIS |
Signed |
34 |
2020-01-16 13:10 |
Anonymous (not verified) |
108.171.132.188 |
B & C Lawn Care Inc |
P.O. Box 55, Boone, IA 50036 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-01-01 |
Caleb Elliott |
onethird4599@gmail.com |
Boone |
Boone |
Iowa |
Katie Frame |
Jessica Carroll |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Caleb Elliott |
onethird4599@gmail.com |
Owner |
Boone |
Boone |
IOWA |
Katie Frame |
Jessica Carroll |
Signed |
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 |
32 |
2020-01-14 10:33 |
Anonymous (not verified) |
108.171.132.189 |
B & C Lawn Care Inc |
P.O. Box 55, Boone, IA 50036 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-01-01 |
Travis Garrett |
onethird4599@gmail.com |
Boone |
Boone |
Iowa |
Katie Frame |
Jessica Carroll |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Travis Garrett |
onethird4599@gmail.com |
Owner |
Boone |
Boone |
IOWA |
Katie Frame |
Jessica Carroll |
Signed |
31 |
2020-01-07 14:30 |
Anonymous (not verified) |
204.155.62.177 |
Money Handling Machines Inc |
PO Box 34218 , OMaha NE 68134 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-01-01 |
Mark Grimes |
daveg@moneyhandlingmanchines.com |
Omaha |
Douglas |
Nebraska |
Michael Bowman |
Joy Nickolte |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dave Grimes |
daveg@moneyhandlingmachines.com |
President |
Omaha |
Douglas |
NE |
Michael Bowman |
Joy Nickolite |
Signed |
30 |
2020-01-07 14:26 |
Anonymous (not verified) |
204.155.62.177 |
Money Handling Machines Inc |
PO Box 34218 , OMaha NE 68134 |
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. |
2020-01-01 |
Scott Grimes |
daveg@moneyhandlingmanchines.com |
Omaha |
Douglas |
Nebraska |
Michael Bowman |
Joy Nickolte |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dave Grimes |
daveg@moneyhandlingmachines.com |
President |
Omaha |
Douglas |
NE |
Michael Bowman |
Joy Nickolite |
Signed |
29 |
2020-01-07 14:24 |
Anonymous (not verified) |
204.155.62.177 |
Money Handling Machines |
PO Box 34218, Omaha NE 68134-0128 |
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. |
2020-01-01 |
Scott Grimes |
daveg@moneyhandlingmanchines.com |
Omaha |
Douglas |
Nebraska |
Michael Bowman |
Joy Nickolte |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David James Grimes |
daveg@moneyhandlingmachines.com |
President |
Omaha |
Douglas |
NE |
Michael Bowman |
Joy Nickolite |
Signed |
28 |
2020-01-07 14:23 |
Anonymous (not verified) |
204.155.62.177 |
Money Handling Machines |
PO Box 34218, Omaha NE 68134-0128 |
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. |
2020-01-01 |
David Jame Grimes |
daveg@moneyhandlingmanchines.com |
Omaha |
Douglas |
Nebraska |
Michael Bowman |
Joy Nickolte |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David James Grimes |
daveg@moneyhandlingmachines.com |
President |
Omaha |
Douglas |
NE |
Michael Bowman |
Joy Nickolite |
Signed |
27 |
2020-01-07 11:03 |
Anonymous (not verified) |
208.95.1.97 |
Rumours Sports Bar and Grill |
309 N 12th Avenue Place Marshalltown IA 50158 |
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. |
2019-11-07 |
Janet Priske |
darla.rowley@insurecentraliowa.com |
Marshalltown |
Marshall |
Iowa |
Darla Rowley |
Samantha Garrison |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Janet Priske |
darla.rowley@insurecentraliowa.com |
Owner |
Marshalltown |
Marshall |
Iowa |
Darla Rowley |
Samantha Garrison |
Signed |
26 |
2020-01-07 11:00 |
Anonymous (not verified) |
208.95.1.97 |
Rumours Sports Bar & Grill |
309 N 12th Ave Place Marshalltown IA 50158 |
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. |
2019-11-07 |
Jason Priske |
darla.rowley@insurecentraliowa.com |
Marshalltown |
Marshall |
Iowa |
Darla Rowley |
Samantha Garrison |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jason Priske |
darla.rowley@insurecentraliowa.com |
Owner |
Marshalltown |
Marshall |
Iowa |
Darla Rowley |
Samantha Garrison |
Signed |
25 |
2020-01-02 09:17 |
Anonymous (not verified) |
207.191.194.182 |
Waukee CabinetWorks LLC |
70 SE Laurel St, Waukee IA 50263 |
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. |
2019-12-23 |
Jason Balm |
chris.rappe@waukeecabinetworks.com |
Waukee |
Dallas |
Iowa |
Chris Andrews |
Dave Creighton Sr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chris Rappe |
chris.rappe@waukeecabinetworks.com |
Operations Manager |
Waukee |
Dallas |
Iowa |
Chris Andrews |
Dave Creighton SR |
Signed |
24 |
2020-01-02 09:12 |
Anonymous (not verified) |
207.191.194.182 |
Waukee CabinetWorks LLC |
70 SE Laurel St, Waukee IA 50263 |
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. |
2019-12-23 |
Amy Balm |
chris.rappe@waukeecabinetworks.com |
Waukee |
Dallas |
Iowa |
Chris Andrews |
Dave Creighton Sr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chris Rappe |
chris.rappe@waukeecabinetworks.com |
Operations Manager |
Waukee |
Dallas |
IA |
Chris Andrews |
Dave Creighton SR |
Signed |
23 |
2019-12-31 09:01 |
Anonymous (not verified) |
65.126.161.162 |
Shawn Watson DBA SW Painting |
1205 13th Ave Orion, IL 61273 |
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. |
2019-12-31 |
Shawn Michael Watson |
None@none.com |
Orion |
Henry |
Illinois |
Sarah Robertson |
Beth Welzenbach |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Shawn Watson |
None@none.com |
Owner |
Orion |
Henry |
Illinois |
Sarah Robertson |
Beth Welzenbach |
Signed |
22 |
2019-12-30 11:30 |
Anonymous (not verified) |
207.191.194.182 |
Bob Stephen Motors Inc |
324 West Main St, Manchester IA 52057 |
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. |
2019-11-05 |
Heidi Roussell |
twyladetrich@gmail.com |
Manchester |
DELAWARE |
IA |
Traci Lyons |
Allie DeVore |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Roussell |
twyladetrich@gmail.com |
President |
MANCHESTER |
Delaware |
IA |
Traci Lyons |
Allie DeVore |
Signed |
21 |
2019-12-30 11:28 |
Anonymous (not verified) |
207.191.194.182 |
Bob Stephen Motors Inc |
324 W Main St, Manchester IA 52057 |
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. |
2019-11-05 |
Paul Roussell |
twyladetrich@gmail.com |
MANCHESTER |
DELAWARE |
IA |
Traci Lyons |
Allie DeVore |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Heidi Roussell |
twyladetrich@gmail.com |
Vice President |
Manchester |
DELAWARE |
IA |
Traci Lyons |
Allie DeVore |
Signed |
20 |
2019-12-30 09:39 |
Anonymous (not verified) |
207.191.194.182 |
LA Trends Addict Inc |
1200 N CENTER POINT RD |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-10-07 |
Laura Frey |
fcrentals1@gmail.com |
HIAWATHA |
Linn |
IA |
Traci Lyons |
Allie DeVore |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Laura Frey |
fcrentals1@gmail.com |
Owner |
HIAWATHA |
Linn |
IA |
Traci Lyons |
Allie DeVore |
Signed |
19 |
2019-12-16 14:04 |
Anonymous (not verified) |
206.80.132.15 |
Cresco Family Dentistry P.C. |
210 N Elm St Cresco, IA 52136 |
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. |
2019-12-16 |
Shirlee J Haw |
cfdentistry@iowatelecom.net |
Cresco |
Howard |
Iowa |
Don Dietzenbach |
Kim Holmes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffrey K Haw |
cfdentistry@iowatelecom.net |
President |
Cresco |
Howard |
Iowa |
Don Dietzenbach |
Kim Holmes |
Signed |
18 |
2019-12-16 14:00 |
Anonymous (not verified) |
206.80.132.15 |
Cresco Family Dentistry P.C. |
210 N Elm St Cresco, IA 52136 |
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. |
2019-12-16 |
Jeffrey K Haw |
cfdentistry@iowatelecom.net |
Cresco |
Howard |
Iowa |
Don Dietzenbach |
Kim Holmes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffrey K Haw |
cfdentistry@iowatelecom.net |
President |
Cresco |
Howard |
Iowa |
Don Dietzenbach |
Kim Holmes |
Signed |
17 |
2019-12-12 13:20 |
Anonymous (not verified) |
65.126.161.162 |
Robert J Schroeder Const. Inc. |
10984 150th St Davenport, IA 52804 |
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. |
2019-12-12 |
Robert J Schroeder |
None@none.com |
Davenport |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert J Schroeder |
None@none.com |
President |
Davenport |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
16 |
2019-12-12 13:17 |
Anonymous (not verified) |
65.126.161.162 |
MGF Concrete DBA Michael Frandsen |
3306 66th Avenue Moline, IL 61265 |
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. |
2019-12-12 |
Michael Frandsen |
None@none.com |
Moline |
Rock Island |
Illinois |
Sarah Robertson |
Beth Welzenbach |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Frandsen |
None@none.com |
Owner |
Moline |
Rock Ilsand |
Illinois |
Sarah Robertson |
Beth Welzenbach |
Signed |