973 |
2024-05-03 11:24 |
Anonymous (not verified) |
94.188.207.227 |
Trent Hatlen |
1042 490th Street, Rembrandt, IA 50576 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-03 |
Trent Hatlen |
trentgotti@yahoo.com |
Rembrandt |
Buena Vista |
Iowa |
Jared Brashears |
Katie Gunkelman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Trent Hatlen |
trentgotti@yahoo.com |
Owner |
Rembrandt |
Buena Vista |
Iowa |
Jared Brashears |
Katie Gunkelman |
Signed |
972 |
2024-05-03 07:35 |
Anonymous (not verified) |
94.188.205.175 |
Outdoor Pros LLC |
6535 WAPSI AVE SE Lone Tree IA 52755 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-02 |
Erik Alberhasky |
erikalberhas@gmail.com |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik Alberhasky |
erikalberhas@gmail.com |
Owner |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
971 |
2024-05-03 07:33 |
Anonymous (not verified) |
94.188.205.176 |
Outdoor Pros LLC |
6535 WAPSI AVE SE Lone Tree IA 52755 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-02 |
Erik Alberhasky |
erikalberhas@gmail.com |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik Alberhasky |
erikalberhas@gmail.com |
Owner |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
970 |
2024-05-02 16:15 |
Anonymous (not verified) |
94.188.205.167 |
Adamantine Spine Moving |
2726 Independence Rd., Iowa City, IA 52240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-02 |
Emily Wallace |
emily.wallace@spinemoving.com |
Des Moines |
Polk |
Iowa |
Margaret Walter |
Dan Walter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William Hoke |
bill.hoke@spinemoving.com |
Owner |
Iowa City |
Johnson |
Iowa |
Sarah Mannix |
Erika Banks |
Signed |
969 |
2024-05-02 16:15 |
Anonymous (not verified) |
94.188.205.175 |
Adamantine Spine Moving |
2726 Independence Rd Iowa City, IA 52240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-02 |
John Clifford Wallace |
cliff.wallace@spinemoving.com |
Des Moines |
Polk |
Iowa |
John Thomas Wallace |
Amanda Root Wallace |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bill Hoke |
bill.hoke@spinemoving.com |
HR |
Des Moines |
Polk |
County |
Sarah Mannix |
Erika Banks |
Signed |
968 |
2024-05-02 13:34 |
Anonymous (not verified) |
94.188.207.227 |
Harman Construction, LLC |
103 NW 6TH ST, POCAHONTAS, IA 50574 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-02 |
DRAKE HARMAN |
harmanconstructionllc@gmail.com |
POCAHONTAS |
POCAHONTAS |
IOWA |
JESSE NEWGARD |
TRACY GROTHAUS |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
DRAKE HARMAN |
harmanconstructionllc@gmail.com |
OWNER |
POCAHONTAS |
POCAHONTAS |
IOWA |
JESSE NEWGARD |
TRACY GROTHAUS |
Signed |
967 |
2024-05-01 06:30 |
Anonymous (not verified) |
94.188.207.224 |
Cael Gulrud |
206 W Main St Calmar, IA, 52132 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-01 |
Brandon Gulrud |
mojopants21@gmail.com |
Waterloo |
Blackhawk |
IA |
Victoria Bacon-Ortiz |
David Gulrud |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cael Gulrud |
gulrud8728@gmail.com |
Owner |
Calmar |
Winneshiek |
IA |
Victoria Bacon-Ortiz |
David Gulrud |
Signed |
966 |
2024-04-30 14:39 |
Anonymous (not verified) |
94.188.207.230 |
Bowman Dozing & Excavating LLC |
218 134th ave 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. |
2024-04-30 |
Bradley D Bowman |
dozermann9@hotmail.com |
Maquoketa |
Jackson |
Iowa |
Jennifer Machande |
Mitchell Schaller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradley D Bowmann |
dozermann9@hotmail.com |
owner/president |
maquoketa |
Jackson |
iowa |
Jennifer Machande |
Mitch Schaller |
Signed |
965 |
2024-04-30 10:47 |
Anonymous (not verified) |
94.188.205.177 |
Billy Dudock |
148818 Argo Fay Rd |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-30 |
Billy Dudock |
mitzi@bruggemanlumber.com |
Thompson |
Carroll |
IL |
Roger Gibbs |
Mitzi Hoeger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Billy Dudock |
mitzi@bruggemanlumber.com |
Self |
Thompson |
Carroll |
Il |
Roger Gibbs |
Mitzi Hoeger |
Signed |
964 |
2024-04-29 19:38 |
Anonymous (not verified) |
94.188.207.226 |
B Squared Construction |
3407 skyline dr Des Moines iowa 50310 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-29 |
Marc Brooker |
bsquared066@gmail.com |
des moines |
polk |
iowa |
Marc Brooker |
Susie brooker |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Coffey Insurance |
kylecoffey@coffeyagency.com |
insurance agent |
des Moines |
polk |
iowa |
marc Brooker |
susie brooker |
Signed |
963 |
2024-04-29 17:42 |
Anonymous (not verified) |
94.188.207.227 |
Total Construction Inc |
4607 S Ridge Rd Sioux City IA 51106 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-29 |
Daniel J Jennett II |
dj_jennett@hotmail.com |
Sioux City |
Woobury |
IA |
Julia L Lesko |
Olivia J Lesko |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel J Jennett II |
dj_jennett@hotmail.com |
President |
Sioux City |
Woodbury |
IA |
Julia L Lesko |
Olivia J Lesko |
Signed |
962 |
2024-04-26 08:46 |
Anonymous (not verified) |
94.188.207.225 |
Gilbert Construction |
3174 Hwy F48 West Newton, Iowa 50208 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-26 |
Christian Gilbert |
christian.gilbert14@gmail.com |
Newton |
Jasper |
Iowa |
Leslie Gilbert |
Shane Gilbert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christian Gilbert |
christian.gilbert14@gmail.com |
worker |
Altoona |
polk |
iowa |
Leslie Gilbert |
Shane Gilbert |
Signed |
961 |
2024-04-25 13:08 |
Anonymous (not verified) |
94.188.207.227 |
PROEFCO LLC |
502 South Cadwell Avenue |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-25 |
Kendy Melendrez Figueroa |
Kendydej@gmail.com |
Eagle Grove |
IA |
United States |
Kendy M Figueroa |
Kendy M Figueroa |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kendy M Figueroa |
Kendydej@gmail.com |
Owner |
Eagle Grove |
IA |
United States |
Kendy M Figueroa |
Kendy M Figueroa |
Signed |
960 |
2024-04-22 18:25 |
Anonymous (not verified) |
94.188.205.174 |
Balvanz Electric LLC |
1517 Greenfield Dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-22 |
Brenton Balvanz |
balvanzelectric@gmail.com |
Marshalltown |
Marshall |
Iowa |
Christin Branon |
Justin Branon |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brenton |
Balvanzelectric@gmail.com |
Owner/President |
Marshalltown |
Marshall |
Iowa |
Christin Branon |
Justin Branon |
Signed |
959 |
2024-04-17 17:42 |
Anonymous (not verified) |
94.188.207.225 |
Simply Lawn and Landscape |
1348 Nature Ct. Van Meter, Iowa 50261 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-17 |
Steven McFarland |
simplylawniowa@gmail.com |
Van Meter |
Madison |
Iowa |
Amber McFarland |
Melody McFarland |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Steven McFarland |
simplylawniowa@gmail.com |
Owner |
Van Meter |
Madison |
Iowa |
Amber McFarland |
Melody McFarland |
Signed |
958 |
2024-04-17 13:16 |
Anonymous (not verified) |
94.188.207.223 |
1st Choice Builders |
10095 Hickman Ct #2 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-17 |
Scott Todd |
scott.todd85@yahoo.com |
West Des Moines |
Polk |
Iowa |
Danielle Pryor |
Ronnie Lee Todd |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott Todd |
scott.todd85@yahoo.com |
self |
West Des Moines |
Polk |
Iowa |
Danielle Pryor |
Ronnie Lee Todd |
Signed |
957 |
2024-04-15 10:15 |
Anonymous (not verified) |
94.188.207.226 |
Calvillo & Son Construction |
1802 Mondamin Ave, Des Moines, Iowa, 50314 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2024-04-15 |
Gerardo Calvillo |
Joedhsanchez@icloud.com |
Des Moines |
Polk |
Iowa |
Agustín Téllez |
Aurora Maciel Colin |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Gerardo Calvillo |
Joedhsanchez@icloud.com |
Owner |
Des Moines |
Polk |
Iowa |
Agustín Téllez |
Aurora Maciel Colin |
Signed |
956 |
2024-04-12 14:23 |
Anonymous (not verified) |
205.221.255.62 |
All things power wash ATP LLC |
2730 Lafayette, Sioux City, IA 51104 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-12 |
Anthony Rowe |
allthingspowerwash4usiouxcity@gmail.com |
Sioux City |
Woodbury |
Iowa |
Franzis Rios |
Tamara Bawi |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Anthony Rowe |
allthingspowerwash4usiouxcity@gmail.com |
Owner |
Sioux City |
Woodbury |
Iowa |
Franzis Rios |
Tamara Bawi |
Signed |
955 |
2024-04-11 10:31 |
Anonymous (not verified) |
94.188.207.228 |
Calvillo & Son Construction |
1802 mondamin ave Des Moines Iowa 50314 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-11 |
Gerardo Calvillo |
joedhsanchez@icloud.com |
Des Moines |
Polk |
Iowa |
Agustín Téllez |
Aurora Maciel Colin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gerardo Calvillo |
joedhsanchez@icloud.com |
Owner |
Des Moines |
Polk |
Iowa |
Agustín Téllez |
Aurora Maciel Colin |
Signed |
954 |
2024-04-08 17:38 |
Anonymous (not verified) |
94.188.205.168 |
Bio-Inspired Design Aeronautics Corp |
6843 Still Creek Pass |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-08 |
Hailey Mitchell |
hailey8.hm@hush.com |
Bettendorf |
Iowa |
United States |
Mike Owens |
Chris DeCock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph Mitchell |
aerotech@hush.com |
President |
Bettendorf |
Iowa |
United States |
Mike Minnich |
Chris DeCock |
Signed |
953 |
2024-04-08 17:35 |
Anonymous (not verified) |
94.188.205.174 |
Bio-Inspired Design Aeronautics Corp |
6843 Still Creek Pass |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-08 |
Hollie Mitchell |
mitchhollie@yahoo.com |
Bettendorf |
Iowa |
United States |
Mike Owens |
Chris DeCock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph Mitchell |
aerotech@hush.com |
President |
Bettendorf |
Iowa |
United States |
Mike Minnich |
Chris DeCock |
Signed |
952 |
2024-04-08 17:25 |
Anonymous (not verified) |
94.188.205.175 |
Bio-Inspired Design Aeronautics Corp |
6843 Still Creek Pass |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-08 |
Joseph Mitchell |
aerotech@hush.com |
Bettendorf |
Iowa |
United States |
Mike Owens |
Chris DeCock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Hollie Mitchell |
mitchhollie@yahoo.com |
Vice President |
Bettendorf |
Iowa |
United States |
Mike Owens |
Chris DeCock |
Signed |
951 |
2024-04-08 10:59 |
Anonymous (not verified) |
94.188.205.167 |
McBee Trucking, LLC |
5029 HARDING ST |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-08 |
Gary McBee |
accounting@mcbeetrucking.com |
Prole |
Warren |
Iowa |
Gary McBee |
Elizabeth Reid |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
GARY MCBEE |
gary@mcbeetrucking.com |
Owner |
PROLE |
IA |
United States |
GARY MCBEE |
Elizabeth Reid |
Signed |
950 |
2024-04-08 07:16 |
Anonymous (not verified) |
94.188.207.223 |
J&J Exteriors |
32670 190th st granger Iowa 50109 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-08 |
Joshua w klein |
jjexteriorsofiowa@gmail.com |
Granger |
Dallas |
Iowa |
Leah klein |
Ethan faughn |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joshua klein |
jjexteriorsofiowa@gmail.com |
Member |
Granger |
Dallas |
Iowa |
Leah klein |
Ethan Faughn |
Signed |
949 |
2024-04-05 20:16 |
Anonymous (not verified) |
94.188.207.223 |
Viramontes Quality Lawncare LLC. |
3029 E Washington Ave Des Moines,Iowa 50317 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-05 |
Andres Viramontes Barron |
a.viramontes1989@gmail.com |
Des Moines |
Iowa |
United States |
Clayton Garrison |
Gloria Cardenas |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andres Viramontes |
a.viramontes1989@gmail.com |
owner |
Des Moines |
Iowa |
United States |
Clayton Garrison |
Gloria Cardenas |
Signed |
948 |
2024-04-05 16:18 |
Anonymous (not verified) |
94.188.205.168 |
Preventive Health Center of Iowa City, PLLC |
221 E College St, Suite 211, Eastwind Healing Center, Iowa City, IA 52240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-05 |
C Andi Woods |
phcic52240@gmail.com |
Iowa City |
Johnson |
ia |
Nancy Martin |
Timmy Ungs |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
C Andi Woods |
phcic52240@gmail.com |
Owner |
Iowa City |
Johnson |
IA |
Nancy Martin |
Timmy Ungs |
Signed |
947 |
2024-04-05 09:55 |
Anonymous (not verified) |
94.188.207.228 |
Foley Contracting LLC |
6730 Double Eagle Dr., 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. |
2024-04-05 |
Samuel Nathan Foley |
foleycontracting@gmail.com |
Davenport |
Scott |
IA |
Gaynelle Warren |
Evon McNeal |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Samuel Foley |
foleycontracting@gmail.com |
Owner |
Davenport |
Scott |
IA |
Gaynelle Warren |
Evon McNeal |
Signed |
946 |
2024-04-04 11:53 |
Anonymous (not verified) |
94.188.205.169 |
Soto Stone LLC |
1071 Mansfield dr waukee iowa 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. |
(2) I decline to reject the employer’s liability coverage. |
2024-04-04 |
Yesser Lenin Juarez Soto |
sotostonellc95@gmail.com |
Waukee |
DALLAS |
Iowa |
Ashley Marie Francisco |
Vincent Alexander Flores |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Yesser Lenin Juarez Soto |
sotostonellc95@gmail.com |
Self |
Waukee |
Dallas |
Iowa |
Ashley Marie Francisco |
Vincent Alexander Flores |
Signed |
945 |
2024-04-03 20:00 |
Anonymous (not verified) |
94.188.207.229 |
Timberview Construction |
803 TIMBERVIEW DR |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-03 |
Parker Evans |
Pcevans28@gmail.com |
ADEL |
IA |
United States |
jason Evans |
Tricia Evans |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Timberview Construction |
Pcevans28@gmail.com |
Myself |
ADEL |
IA |
United States |
Jason Evans |
Tricia Evans |
Signed |
944 |
2024-04-03 16:51 |
Anonymous (not verified) |
94.188.205.166 |
Butcher Insurance & Financial Services, Inc. |
220 5th Ave S Clinton, IA 52732 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-03 |
David E Butcher |
dave.butcher.efmk@statefarm.com |
Galena |
JoDaviess |
Illinois |
Sabra Petersen |
Klark Sikkema |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Butcher |
dave.butcher.efmk@statefarm.com |
President |
Galena |
JoDaviess |
Illinois |
Sabra Petersen |
Klark Sikkema |
Signed |
943 |
2024-04-03 12:07 |
Anonymous (not verified) |
94.188.205.166 |
Invisible Fence of NCI, Inc |
408 5th St, Ste 100 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-04 |
Paul Andy Timm |
ifbcentraliowa@yahoo.com |
Madrid |
IA |
Iowa |
Lisa Timm |
Kari Rigby |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa Busch Timm |
centraliowa@invisiblefence.com |
Spouse |
Madrid |
IA |
United States |
Lisa Timm |
Kari Rigby |
Signed |
942 |
2024-04-03 12:06 |
Anonymous (not verified) |
94.188.205.174 |
Invisible Fence of NCI, Inc |
408 5th St, Ste 100 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-04 |
Lisa Busch Timm |
centraliowa@invisiblefence.com |
Madrid |
Iowa |
United States |
Paul Timm |
Kari Rigby |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa Busch Timm |
centraliowa@invisiblefence.com |
Self |
Madrid |
IA |
United States |
Paul Timm |
Kari Rigby |
Signed |
941 |
2024-04-03 10:26 |
Anonymous (not verified) |
94.188.207.223 |
Andrew Renna |
407 19th st spirit lake Iowa 51369 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-03 |
Andrew John Renna |
drewrenna86@gmail.com |
Spirit lake |
Dickinson |
Iowa |
Brianna Lene |
Nicholas Omang |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andrew Renna |
drewrenna86@gmail.com |
Owner |
Spirit lake |
Dickinson |
Iowa |
Brianna Lene |
Nicholas Omang |
Signed |
940 |
2024-04-03 07:49 |
Anonymous (not verified) |
94.188.205.167 |
Wildride Trucking |
3261 old river rd sw. Cedar Rapids Ia |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-03 |
David mckee |
wildride1969@gmail.com |
Cedar Rapids |
Lynn |
Ia |
Valerie mckee |
Dillon Williams |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dave mckee |
wildride1969@gmail.com |
Owner |
Cedar Rapids |
Lynn |
Ia |
Valerie mckee |
Dillon Williams |
Signed |
939 |
2024-04-01 11:44 |
Anonymous (not verified) |
94.188.207.228 |
SFA INC |
955 31ST MARION, IA 52302-3788 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-01 |
SARAH FERRETER |
sarah@sfacpa.com |
MARION |
LINN |
IOWA |
WILLIE CALDWELL |
ALEXANDRA BACHMAN |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
WILLIE CALDWELL |
WILLIE.CALDWELL.B2SH@STATEFARM.COM |
AGENT |
CEDAR RAPIDS |
LINN |
IOWA |
WILLIE CALDWELL |
ALEXANDRA BACHMAN |
Signed |
938 |
2024-04-01 07:12 |
Anonymous (not verified) |
94.188.207.225 |
Martinez HVAC Construction LLC |
512 Anderson st jewell IA 50130 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-01 |
Felipe Martinez |
miguelrmartinez26@gmail.com |
Jewell |
Hamilton |
IA |
Brady Cooper |
Job Cooper |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Felipe Martinez |
miguelrmartinez26@gmail.com |
owner |
Jewell |
Hamilton |
IA |
Brady Cooper |
Job Cooper |
Signed |
937 |
2024-03-30 17:30 |
Anonymous (not verified) |
94.188.205.167 |
AR Drilling LLC |
1821 Roebling Rd, Adel, IA 50003 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-30 |
Luis Serrano |
serranoluis7667@gmail.com |
Adel |
Dallas |
IA |
Kelly green |
Thomas Green |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Luis Serrano |
serranoluis7667@gmail.com |
Owner |
Adel |
Dallas |
IA |
Kelly Green |
Thomas Green |
Signed |
936 |
2024-03-30 16:41 |
Anonymous (not verified) |
94.188.205.176 |
Rhubarb Botanicals LLC |
650 Martelle Rd, Springville IA 52336 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-30 |
Emma Barber |
emma@rhubarbbotanicals.com |
Springville |
Linn |
Iowa |
Lena Wilhelm |
Harvey Wilhelm |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Emma Barber |
emma@rhubarbbotanicals.com |
Co-Owner |
Springville |
Linn |
Iowa |
Lena Wilhelm |
Harvey Wilhelm |
Signed |
935 |
2024-03-25 08:25 |
Anonymous (not verified) |
94.188.205.166 |
Panell Industries, LLC |
5850 russel Dr ste2. Lincoln Ne 68507 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-25 |
Gaddiel Medina Panell |
gaddiel@panellindustriesllc.com |
Grand River, IA |
united state |
IOWA |
Richard Bruno |
Migdalia Panell |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Gaddiel Medina Panell |
gaddiel@panellindustriesllc.com |
owner |
Grand River, Iowa |
decator |
iowa |
Richard Bruno |
Migdalia Panell |
Signed |
934 |
2024-03-24 19:23 |
Anonymous (not verified) |
94.188.207.230 |
Dave Mckee |
3261 old river rd sw Cedar Rapids Ia 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-23 |
Dave mckee |
wildride1969@gmail.com |
Cedar Rapids |
Lynn |
Ia |
Dave mckee |
Valerie mckee |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dave mckee |
wildride1969@gmail.com |
Owner |
Cedar Rapids |
Lynn |
Ia |
David mckee |
Valerie mckee |
Signed |
933 |
2024-03-22 21:55 |
Anonymous (not verified) |
94.188.205.176 |
Alternative Sport Enterprises |
101 Highway 1 West Iowa City IA 52246 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-22 |
James Michael Pearson |
hatchetjacksiowa@gmail.com |
Savage |
Scott County |
Minnesota |
Payton Kahl |
Trey Kahl |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nick John Carroll |
hatchetjacksiowa@gmail.com |
Owner |
CORALVILLE |
Johnson County |
Iowa |
Payton Kahl |
Trey Kahl |
Signed |
932 |
2024-03-22 21:55 |
Anonymous (not verified) |
94.188.205.175 |
Alternative Sport Enterprises |
101 Highway 1 West Iowa City IA 52246 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-22 |
Nick John Carroll |
hatchetjacksiowa@gmail.com |
CORALVILLE |
Johnson County |
Iowa |
Payton Kahl |
Trey Kahl |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Michael Pearson |
hatchetjacksiowa@gmail.com |
Owner |
Savage |
Scott County |
Minnesota |
Payton Kahl |
Trey Kahl |
Signed |
931 |
2024-03-21 20:54 |
Anonymous (not verified) |
94.188.207.228 |
Cnr drywall llc |
410 w 6th st muscatine Iowa 52761 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-21 |
Jair Romo |
cnrdrywall@gmail.com |
Muscatine |
Muscatine |
Iowa |
Jordy tenorio |
Emmanuel Nunez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cnr drywall |
cnrdrywall@gmail.com |
Owner |
Muscatine |
Muscatine |
Ia |
Jordy tenorio |
Emmanuel Nunez |
Signed |
930 |
2024-03-21 20:44 |
Anonymous (not verified) |
94.188.207.229 |
Southeast Iowa Precision Painting |
714 Lincoln St Ainsworth IA 52201 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-21 |
Kirby Jay Shetler |
kirbyshetler@gmail.com |
Ainsworth |
Washington |
Iowa |
Kirby Shetler |
Demi Shetler |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Southeast Iowa Precision Painting |
kirbyshetler@gmail.com |
Owner |
Ainsworth |
Washington |
Iowa |
Kirby Shetler |
Demi Shetler |
Signed |
929 |
2024-03-21 19:00 |
Anonymous (not verified) |
94.188.205.167 |
Stewart and Belzer Construction |
1103 n 8th Ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-21 |
Logan belzer |
lbelzer1999@gmail.com |
Washington |
Washington |
Iowa |
Joseph Stewart |
Graham Hagge |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Logan belzer |
lbelzer1999@gmail.com |
Owner |
Washington |
Washington |
Iowa |
Joseph Stewart |
Graham Hagge |
Signed |
928 |
2024-03-21 16:20 |
Anonymous (not verified) |
94.188.207.230 |
Midwest Premier Painting |
5496 Hunt Rd, Burlington IA 52601 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-21 |
Christopher West |
cswest1974@yahoo.com |
Burlington |
Des Moines |
IA |
Amy West |
McKenzie West |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christopher West |
cswest1974@yahoo.com |
Owner |
Burlington |
Des Moines |
IA |
Amy Wets |
McKenzie West |
Signed |
927 |
2024-03-20 23:27 |
Anonymous (not verified) |
94.188.205.177 |
RRB, LLC |
4444 1st Ave NE Ste 510 Cedar Rapids, IA 52402 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-20 |
Kelli Holton |
kelli@rebelroseboutique.co |
Coralville |
IA |
United States |
Dave Booth |
Ann Holton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kelli Holton |
kelli@rebelroseboutique.co |
Owner |
Coralville |
IA |
United States |
Dave Booth |
Ann Holton |
Signed |
926 |
2024-03-20 15:25 |
Anonymous (not verified) |
94.188.207.230 |
CML Constuction LLC |
2116 Park Ave Muscatine, Iowa 52761 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-20 |
CHRIS LINNENKAMP |
cmlconstructionllc@gmail.com |
Muscatine |
IA |
IA |
Gabriel Diaz |
Byron Lopez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CHRIS LINNENKAMP |
cmlconstructionllc@gmail.com |
Owner |
Muscatine |
IA |
IA |
Gabriel Diaz |
Byron Lopez |
Signed |
925 |
2024-03-20 14:08 |
Anonymous (not verified) |
94.188.207.225 |
Magels concrete cutting and drilling services inc |
13554 124th ave Burlington iowa 52601 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-01 |
Trent magel |
tmagel123@gmail.com |
Burlington |
Des moines |
Iowa |
Tamara crawford |
Joseph Messer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Trent magel |
tmagel123@gmail.com |
Owner |
Burlington |
Des moines |
Iowa |
Tamara crawford |
Justice christensen |
Signed |
924 |
2024-03-19 16:40 |
Anonymous (not verified) |
94.188.207.228 |
Brite-Way Services Inc. |
621 Morningside Dr., Burlington IA 52601 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-19 |
Richard Luckenbill |
britewayburl@gmail.com |
Burlington |
Iowa |
Iowa |
Tammy Luckenbill |
Brooke Mathiasmeier |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Richard Luckenbill |
britewayburl@gmail.com |
Owner, President |
Burlington |
Iowa |
Iowa |
Tammy Luckenbill |
Brooke Mathiasmeier |
Signed |
923 |
2024-03-19 13:53 |
Anonymous (not verified) |
94.188.207.224 |
Hawki Housing Solutions LLC |
5036 Highway 61 Burlington, Iowa 52601 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-19 |
Kyle Carruthers |
carruthershunters@gmail.com |
Burlington |
Des Moines |
IOWA |
Laura Carruthers |
Allice Smith |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kyle Carruthers |
carruthershunters@gmail.com |
Owner |
Burlington |
Des Moines |
IOWA |
Laura Carruthers |
Allice Smith |
Signed |
922 |
2024-03-19 13:19 |
Anonymous (not verified) |
94.188.205.169 |
Stephen D. Seils |
314 East Clevland Street, New London, IA 52645 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-09 |
Stephen Dwight Seils |
sdseils43@gmail.com |
New London |
Henry |
Iowa |
Josh Horn |
Dan Hollingsworth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Stephen D. Seils |
sdseils43@gmail.com |
Owner |
New London |
Henry |
Iowa |
Josh Horn |
Dan Hollingsworth |
Signed |
921 |
2024-03-18 15:45 |
Anonymous (not verified) |
94.188.207.226 |
Great Tree LLC |
2701 e douglas ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-18 |
Timothy Buell |
treeshark52@gmail.com |
Des Moines |
IA |
United States |
ryan homan |
Jamarlo fields |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert buell |
Greattree55@gmail.com |
company owner |
Des Moines |
IA |
United States |
ryan homan |
jamarlo fields |
Signed |
920 |
2024-03-18 15:42 |
Anonymous (not verified) |
94.188.207.223 |
Great Tree LLC |
2701 e douglas ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-18 |
Robert buell |
Greattree55@gmail.com |
Des Moines |
IA |
United States |
ryan homan |
Jamarlo fields |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert buell |
Greattree55@gmail.com |
company owner |
Des Moines |
IA |
United States |
ryan homan |
jamarlo fields |
Signed |
919 |
2024-03-11 14:32 |
Anonymous (not verified) |
94.188.207.226 |
DeJear Inc. |
3220 SW 34th Street, Des Moines, Iowa 50321 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-11 |
Deidre Olivia DeJear |
deidre.dejear@gmail.com |
Des Moines |
Polk |
Iowa |
Rory Robson |
Geoff Matlock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Marvin Leo DeJear Jr |
dejear@dejearcorporation.com |
Chief Administrative Officer |
Des Moines |
Polk |
Iowa |
Rory Robson |
Geoff Matlock |
Signed |
918 |
2024-03-11 14:29 |
Anonymous (not verified) |
94.188.207.224 |
DeJear Inc. |
3220 SW 34th Street, Des Moines, Iowa 50321 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-11 |
Marvin L. DeJear Jr |
marvin.dejear@gmail.com |
Des Moines |
Polk |
Iowa |
Rory Robson |
Geoff Matlock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Marvin L. DeJear Jr |
dejear@dejearcorporation.com |
Chief Administrative Officer |
Des Moines |
Polk |
Iowa |
Rory Robson |
Geoff Matlock |
Signed |
917 |
2024-03-11 12:51 |
Anonymous (not verified) |
94.188.205.168 |
Hernandez Construction KD |
119 W Maxson Ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-11 |
Juan Santiago Hernandez |
chagodoki74@gmail.com |
West Liberty |
Muscatine |
Iowa |
Kevin Kofron |
Kiara Hernandez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Juan Santiago Hernandez |
chagodoki74@gmail.com |
Owner |
West Liberty |
Muscatine |
Iowa |
Kevin Kofron |
Kiara Hernandez |
Signed |
916 |
2024-03-09 12:47 |
Anonymous (not verified) |
94.188.205.174 |
Iowa Turf Management |
3218 castle dr sw, Cedar Rapids IA 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-09 |
Larrion Eason |
Iowaturfmanagement@gmail.com |
cedar rapids |
linn |
Iowa |
Shayla Jameson |
Shyann Jameson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Larrion Eason |
Iowaturfmanagement@gmail.com |
self |
cedar rapids |
linn |
Iowa |
Shayla Jameson |
Shyann Jameson |
Signed |
915 |
2024-03-08 13:24 |
Anonymous (not verified) |
94.188.205.174 |
One Call Exterior LLC |
1918 9th St Des Moines 50314 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-08 |
Nancy G Lopez |
onecallexteriors@gmail.com |
Des Moines |
Polk |
IA |
Monica Martinez |
Noe Ordaz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nancy G Lopez |
onecallexteriors@gmail.com |
Self |
Ames |
Story |
IA |
Monica Martinez |
Noe Ordaz |
Signed |
914 |
2024-03-08 09:02 |
Anonymous (not verified) |
94.188.205.167 |
Lubbock Construction Inc |
3035 66 St Shellsburg IA 52332 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-08 |
Justin L Lubbock |
justinlubbock@yahoo.com |
Shellsburg |
Benton |
IA |
Cherie Lynn Scott |
Jodie Marie Little |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Justin L Lubbock |
justinlubbock@yahoo.com |
President |
Shellsburg |
Benton |
IA |
Cherie Lynn Scott |
Jodie Marie Little |
Signed |
913 |
2024-03-07 07:46 |
Anonymous (not verified) |
94.188.207.229 |
Fair Trade Acoustical Ceiling Services |
3837 5th ave Des Moines, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-07 |
Mathew Bingaman |
Bingaman.matthew1@gmail.com |
Des Moines |
Polk |
Iowa |
Jamie Rose |
Dmitri Mejia |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mathew Bingaman |
Bingaman.matthew1@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Jamie Rose |
Dmitri Mejia |
Signed |
912 |
2024-03-06 16:44 |
Anonymous (not verified) |
94.188.205.174 |
NeX Level Moving LLC |
5634 Deerwood ST SW, Cedar Rapids, IA 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-06 |
Treyton Tayvon Mims |
treytmims@gmail.com |
Cedar Rapids |
Linn |
IA |
Jessica Mims |
Travis Mims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Treyton Tayvon Mims |
treytmims@gmail.com |
self |
Cedar Rapids |
Linn |
IA |
Jessica Mims |
Travis Mims |
Signed |
911 |
2024-03-02 14:34 |
Anonymous (not verified) |
94.188.205.168 |
Gerlich Enterprises |
2824 Hickory Hills Ln |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-02 |
Garrett Gerlich |
paul@gerlich.io |
Bettendorf |
scott |
IA |
Paul Gerlich |
Kelsey Gerlich |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Gerlich |
paul@gelrich.io |
Owner |
Bettendorf |
Scott |
Iowa |
Kelsey Gerlich |
Elora Gerlich |
Signed |
910 |
2024-03-02 14:34 |
Anonymous (not verified) |
94.188.207.224 |
Gerlich Enterprises |
2824 Hickory Hills Ln |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-02 |
Elora Gerlich |
paul@gerlich.io |
Bettendorf |
scott |
IA |
Paul Gerlich |
Kelsey Gerlich |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Gerlich |
paul@gelrich.io |
Owner |
Bettendorf |
Scott |
Iowa |
Kelsey Gerlich |
Garrett Gerlich |
Signed |
909 |
2024-03-02 14:33 |
Anonymous (not verified) |
94.188.207.224 |
Gerlich Enterprises |
2824 Hickory Hills Ln |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-02 |
Kelsey Gerlich |
paul@gerlich.io |
Bettendorf |
scott |
IA |
Paul Gerlich |
Elora Gerlich |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Gerlich |
paul@gelrich.io |
Owner |
Bettendorf |
Scott |
Iowa |
Elora Gerlich |
Garrett Gerlich |
Signed |
908 |
2024-03-02 14:33 |
Anonymous (not verified) |
94.188.207.230 |
Gerlich Enterprises |
2824 Hickory Hills Ln |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-02 |
Paul Gerlich |
paul@gerlich.io |
Bettendorf |
scott |
IA |
Kelsey Gerlich |
Elora Gerlich |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Gerlich |
paul@gelrich.io |
Owner |
Bettendorf |
Scott |
Iowa |
Kelsey Gerlich |
Garrett Gerlich |
Signed |
907 |
2024-03-01 12:13 |
Anonymous (not verified) |
94.188.207.230 |
Bulls Eye Builders Llc |
406 E South st Mechanicsville Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-01 |
Timothy Hansel |
bullseyebuildersllc@gmail.com |
Mechanicsville |
Cedar |
Iowa |
Kevin Kofron |
Jackie hart |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Timothy Hansel |
bullseyebuildersllc@gmail.com |
Owner |
Mechanicsville |
Iowa |
United States |
Kevin Kofron |
Jackie Hart |
Signed |
906 |
2024-02-29 16:16 |
Anonymous (not verified) |
94.188.205.168 |
Bradley K. Gaul Handyman Services |
740 Cedar Valley Road, Tipton, IA 52772 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-29 |
Bradley Keith Gaul |
bjgjal33@aol.com |
Tipton |
Cedar |
Iowa |
Jill Lynette Gaul |
Logan Benjamin Gaul |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradley Keith Gaul |
bjgjal33@aol.com |
Self |
Tipton |
Cedar |
Iowa |
Jill Lynette Gaul |
Logan Benjamin Gaul |
Signed |
905 |
2024-02-28 11:47 |
Anonymous (not verified) |
94.188.207.228 |
Monarca General Builders LLC |
551 Martin Rd Waterloo Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-01 |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
Presidente |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
904 |
2024-02-28 06:52 |
Anonymous (not verified) |
94.188.205.167 |
Monarca General Builders LLC. |
551 Martin Rd Waterloo Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-28 |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
President |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
903 |
2024-02-27 13:54 |
Anonymous (not verified) |
94.188.205.166 |
MELTZ'S CONSTRUCTION LLC |
402 Jennifer Ln NE Cedar Rapids IA 52402 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-27 |
RICARDO MELTZ |
waymakeranasolorzano@gmail.com |
CADAR RAPIDS |
IA |
United States |
Lysandra Betancourt |
Belkis S Diaz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
ALAN SALGADO |
alan@prime-agents.com |
OWNER |
IRVING |
TX |
United States |
Lysandra Betancourt |
Belkis S Diaz |
Signed |
902 |
2024-02-26 11:37 |
Anonymous (not verified) |
94.188.207.228 |
roorda dairy llc |
5128 460th st |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-22 |
scott roorda |
scottyroorda@hotmail.com |
granville |
obrien county |
iowa |
lance roorda |
larry roorda |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
kyle blankers |
kyle@veinsurance.com |
member |
5128 460th st |
obrien county |
iowa |
lance roorda |
larry roorda |
Signed |
901 |
2024-02-26 11:02 |
Anonymous (not verified) |
94.188.207.227 |
roorda dairy llc |
5128 460th st |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-22 |
larry roorda |
lgroorda@gmail.com |
paullina |
obrien county |
iowa |
lance roorda |
scott roorda |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
kyle blankers |
kyle@veinsurance.com |
member |
5128 460th st |
obrien county |
iowa |
lance roorda |
scott roorda |
Signed |
900 |
2024-02-26 11:00 |
Anonymous (not verified) |
94.188.207.226 |
roorda dairy llc |
5128 460th st |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-22 |
lance roorda |
lgroorda@gmail.com |
sioux center |
sioux county |
iowa |
larry roorda |
scott roorda |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
kyle blankers |
kyle@veinsurance.com |
member |
5128 460th st |
obrien county |
iowa |
larry roorda |
scott roorda |
Signed |
899 |
2024-02-25 18:18 |
Anonymous (not verified) |
94.188.207.229 |
Michael D Clark |
324 main st Bennett Iowa 52721 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-25 |
Michael D Clark |
michaeld3705@gmail.com |
Bennett |
Cedar |
Iowa |
Davia Dawn Kelley |
Tabetha Jean Widmer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael D Clark |
michaeld3705@gmail.com |
Owner |
Bennett |
Cedar |
Iowa |
Davia Dawn Kelley |
Tabetha Jean Widmer |
Signed |
898 |
2024-02-24 21:06 |
Anonymous (not verified) |
94.188.207.226 |
Under Pressure Pressure on |
1008 Doubletree 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. |
2024-02-24 |
Kevin M Feeney |
kevin.feeney45@gmail.com |
Cedar Rapids |
IA |
United States |
Taryn Erbes |
Susan Erbes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kevin M Feeney |
kevin.feeney45@gmail.com |
Owner |
Cedar Rapids |
IA |
United States |
Taryn Erbes |
Susan Erbes |
Signed |
897 |
2024-02-24 18:40 |
Anonymous (not verified) |
94.188.205.169 |
Rays Plumbing Heating & Air conditioning LLC. |
305 Cedar St. Tipton Iowa 52772 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-02-24 |
Raymond Zaruba |
raymondzaruba@gmail.com |
TIPTON |
IA |
United States |
Kevin Kofron |
Jodi Kofron |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Raymond Zaruba |
raymondzaruba@gmail.com |
Owner |
Tipton Iowa 52772 |
Cedar |
Iowa |
Kevin Kofron |
Jodi Kofron |
Signed |
896 |
2024-02-23 16:14 |
Anonymous (not verified) |
94.188.205.167 |
Convenience Stores Business Inc |
1615 Bishop Ave, Waterloo, IA 50707 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2025-02-26 |
John Sarwar |
trampride@aol.com |
Waterloo |
Black Hawk |
IA |
. |
. |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jason Koch |
jason_koch@veridiancu.org |
Agent |
Waterloo |
Black Hawk |
IA |
. |
. |
Signed |
895 |
2024-02-23 14:59 |
Anonymous (not verified) |
94.188.205.169 |
Pas Construction LLC. |
1125 Hubbard Ave Ne. Cedar rapids Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-23 |
Steven M. Helle |
helle4513@gmail.com |
Fairfax |
Linn |
Iowa |
Claudia Venable |
Matthew Himmel |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Steven Helle |
helle4513@gmail.com |
Owner |
Fairfax |
Linn |
Iowa |
Claudia Venable |
Matthew Himmel |
Signed |
894 |
2024-02-23 08:17 |
Anonymous (not verified) |
94.188.207.226 |
MIDSTATE SOLUTION LLC |
107 Harrison Dr Baxter, IA 50028 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-23 |
Kenneth Schlosser |
schlosser64@icloud.com |
Colfax |
Jasper |
IA |
Kinley Bethards |
Grant Alexander |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Justin Myers |
justinm@midstatesolution.com |
Owner |
Baxter |
Jasper |
IA |
Kinley Bethards |
Grant Alexander |
Signed |
893 |
2024-02-22 10:29 |
Anonymous (not verified) |
94.188.207.226 |
Sierra Roofing |
401 W 15th Street West Liberty, IA 52776 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-22 |
Abraham Granjeno Sierra |
absierra89@gmail.com |
West Liberty |
Muscatine |
Iowa |
Claudia Venable |
Dan Saunders |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Abraham Granjeno Sierra |
absierra89@gmail.com |
Owner/Self |
West Liberty |
Muscatine |
Iowa |
Claudia Venable |
Dan Saunders |
Signed |
892 |
2024-02-21 16:55 |
Anonymous (not verified) |
94.188.205.167 |
NeX Level Restoration |
314 8th ST NW Cedar Rapids, IA 52405 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-21 |
Kenneth Williams |
kncwilliams@msn.com |
Cedar Rapids |
Linn |
Iowa |
Sabrina Lovell |
Tiffany Williams |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kenneth Williams |
kncwilliams@msn.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Sabrina Lovell |
Tiffany Williams |
Signed |
891 |
2024-02-19 12:09 |
Anonymous (not verified) |
94.188.205.169 |
FJ Orisa Construction Inc |
114 Austin Street SW |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-19 |
Felipe Aldana |
FJOrisaconstruction@yahoo.com |
Cedar Rapids |
Linn |
IA |
Karen Sedlacek |
Billie Jo Moore |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Felipe Aldana |
FJOrisaconstruction@yahoo.com |
officer |
Cedar Rapids |
Iowa |
Iowa |
Karen Sedlacek |
Billie Jo Moore |
Signed |
890 |
2024-02-19 12:07 |
Anonymous (not verified) |
94.188.205.174 |
FJ Orisa Construction Inc |
114 Austin Street SW |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-19 |
Jennifer LynnWeirup |
FJOrisaconstruction@yahoo.com |
Cedar Rapids |
Linn |
IA |
Karen Sedlacek |
Billie Jo Moore |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
jennifer lynn weirup |
FJOrisaconstruction@yahoo.com |
self |
Cedar Rapids |
Iowa |
Iowa |
Karen Sedlacek |
Billie Jo Moore |
Signed |
889 |
2024-02-15 13:16 |
Anonymous (not verified) |
94.188.207.228 |
Five Star Hardwood LLC |
3510 King Dr SW |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-15 |
Kenneth Williams |
kncwilliams@msn.com |
Cedar Rapids |
Linn |
IA |
Sabrina Lovell |
Tiffany Williams |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kenneth Williams |
kncwilliams@msn.com |
Owner |
Cedar Rapids |
Linn |
IA |
Sabrina Lovell |
Tiffany Williams |
Signed |
888 |
2024-02-12 12:35 |
Anonymous (not verified) |
94.188.205.167 |
Standard Builders DBA Midwest Seamless |
1930 e army post rd., Des Moines IA |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-12 |
Andy and Axell Construction LLC |
bradymaher9@gmail.com |
Des Moines |
Polk |
IA |
Michael Maher |
Brady Maher |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
michael maher |
mikemaher@midwestseamless.com |
Owner/President |
PRAIRIE CITY |
Jasper |
IA |
Brady Maher |
fernando perez |
Signed |
887 |
2024-02-08 13:40 |
Anonymous (not verified) |
94.188.207.228 |
Paradigm Construction |
3263 Cumming Rd. Cumming, IA 50061 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-08 |
Justin Huss |
jmanhuss@gmail.com |
Grimes |
Polk |
Iowa |
Katie Hennessey |
Ryan Shabino |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ryan Shabino |
office@prdgmgroup.com |
Owner |
Cumming |
Warren |
Iowa |
Katie Hennessey |
Nicole Shabino |
Signed |
886 |
2024-02-06 19:20 |
Anonymous (not verified) |
94.188.207.227 |
juan carlos ruiz perez |
2010 seventh st desmoines, ia 50314 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-06 |
juan carlos ruiz perez |
jruizperez898@gmail.com |
desmoines |
polk |
iowa |
guadalupe Gonzalez rojo |
Javier Villeda Hernandez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
juan c ruiz perez |
jruizperez898@gmail.com |
owner |
desmoines |
polk |
in |
guadalupe gonzalez rojo |
Javier Villeda Hernandez |
Signed |
885 |
2024-02-06 15:20 |
Anonymous (not verified) |
94.188.205.177 |
JUAN GOMEZ LOPEZ |
833 E UNIVERSITY AVE, DESMOINES,IA APT 1 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-06 |
JUAN GOMEZ LOPEZ |
juangomezlopez057@gmail.com |
desmoines |
polk |
IOWA |
PRICILA RUBI MONDRAGON |
pedro gomez lopez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
juan gomez lopez |
juangomezlopez057@gmail.com |
owner |
desmoines |
polk |
iowa |
pricila rubi mondragon |
pedro gomez lopez |
Signed |
884 |
2024-02-05 11:31 |
Anonymous (not verified) |
94.188.205.175 |
NeX Level Moving LLC |
5634 Deerwood ST SW cedar rapids iowa 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-05 |
Robert Sanders |
Sandersrob101300@gmail.com |
Cedar Rapids |
Linn |
Iowa |
dallas haul |
johntay buck |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Sanders |
Sandersrob101300@gmail.com |
self |
cedar rapids |
linn |
iowa |
dallas haul |
Johntay buck |
Signed |
883 |
2024-02-05 11:29 |
Anonymous (not verified) |
94.188.205.175 |
Nex Level Moving LLC |
5634 Deerwood ST SW cedar rapids iowa 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-05 |
Robert Sanders |
Sandersrob101300@gmail.com |
Cedar Rapids |
Linn |
Iowa |
n/a |
n/a |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Sanders |
Sandersrob101300@gmail.com |
self |
cedar rapids |
linn |
iowa |
n/a |
n/a |
Signed |
882 |
2024-02-05 11:18 |
Anonymous (not verified) |
94.188.205.175 |
next level moving |
1186 Capital Dr Sw cedar rapids 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. |
(2) I decline to reject the employer’s liability coverage. |
2024-02-05 |
Robert Sanders |
sandersrob101300@gmail.con |
cedar rapids |
linn |
iowa |
phoenix sims |
n/a |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
next level moving |
tarin.nexlevelmoving@gmail.com |
labor |
cedar rapids |
linn |
iowa |
n/a |
n/a |
Signed |
881 |
2024-02-05 11:08 |
Anonymous (not verified) |
94.188.205.168 |
Nxt Level |
1186 Capital Dr sw |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation 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. |
2024-02-05 |
Robert Sanders |
Sandersrob101300@gnail.com |
cedar rapids |
Linn |
iowa |
n/a |
n/a |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
next level |
nextlevelmoving@gmail.com |
labor |
cedar rapids |
linn |
iowa |
n/a |
n/a |
Signed |
880 |
2024-02-04 18:45 |
Anonymous (not verified) |
94.188.205.176 |
One Call Exteriors |
1928 9th St Des Moines IA 50314 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-04 |
Nancy López |
onecallexteriors@gmail.com |
Des Moines |
Polk |
IA |
Noé Ordaz |
Angie Florian |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nancy López |
onecallexteriors@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Noé Ordaz |
Angie Florian |
Signed |
879 |
2024-02-02 15:24 |
Anonymous (not verified) |
94.188.205.169 |
Open Road Driving School.com INC |
2418 Paradise Ct Kalona, Iowa 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. |
2024-02-02 |
Jennifer Turner |
jenny@openroaddrivingschool.com |
Kalona |
Washington |
Iowa |
Lonnie Slabaugh |
Joshua Turner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jennifer Turner |
jenny@openroaddrivingschool.com |
president |
Kalona |
Washington |
Iowa |
Lonnie Slabaugh |
Joshua Turner |
Signed |
878 |
2024-02-02 15:22 |
Anonymous (not verified) |
94.188.207.223 |
Open Road Driving School.com INC |
2418 Paradise Ct Kalona, Iowa 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. |
2024-02-02 |
Ryan Turner |
ryanturner@citypoint.cc |
Kalona |
Washington |
IOwa |
Lonnie Slaubaugh |
Joshua Turner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ryan Turner |
ryanturner@citypoint.cc |
Secretary |
Kalona |
Washington |
Iowa |
Lonnie Slabaugh |
Joshua Turner |
Signed |
877 |
2024-01-30 17:58 |
Anonymous (not verified) |
94.188.207.230 |
Erik Mortens |
9823 nw 46th ct polk city iowa 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-30 |
Steffanie Mortens |
steffanie.mortens@gmail.com |
Polk city |
Polk |
Iowa |
Andrea Davis |
Kali Davis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik mortens |
Erik.mortens@gmail.com |
Self |
Polk city |
Polk |
Iowa |
Kali Davis |
Andrea Davis |
Signed |
876 |
2024-01-30 17:55 |
Anonymous (not verified) |
94.188.207.230 |
Erik Mortens |
9823 nw 46th ct polk city iowa 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-30 |
Erik mortens |
Erik.mortens@gmail.com |
Polk city |
Polk |
Iowa |
Andrea Davis |
Kali Davis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik mortens |
Erik.mortens@gmail.com |
Self |
Polk city |
Polk |
Iowa |
Kali Davis |
Andrea Davis |
Signed |
875 |
2024-01-30 14:18 |
Anonymous (not verified) |
94.188.207.226 |
Central Athletics LLC |
7 S 4th Street Council Bluffs Iowa 51503 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-30 |
Cait Boyer |
centralathleticsia@gmail.com |
Council Bluffs |
Pottawattamie |
Iowa |
Justice Woolard |
Erin Eby |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cait Boyer |
centralathleticsia@gmail.com |
President |
Council Bluffs |
Pottawattamie |
Iowa |
Justice Woolard |
Erin Eby |
Signed |
874 |
2024-01-29 14:30 |
Anonymous (not verified) |
94.188.205.174 |
Proefco LLC |
502 s Cadwell AVE |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-30 |
Kendy Melendrez |
kendydej@gmail.com |
Eagle Grove |
IA |
IA |
Kendy Melendrez |
Jaime Hernandez |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Kendy Melendrez |
kendydej@gmail.com |
owner |
Eagle Grove |
IA |
IA |
Kendy Melendrez |
Jaime Hernandez |
Signed |
873 |
2024-01-26 12:02 |
Anonymous (not verified) |
94.188.207.224 |
Bowlerama, Inc. |
1313 East Diehl St. Des Moines, IA 50315 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-26 |
Michael Klimpel |
Klimpel@aol.com |
Rosemount |
MN |
United States |
Eric Stahl |
Connie Hill |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Michael Klimpel |
Klimpel@aol.com |
President |
Rosemount |
MN |
United States |
Eric Stahl |
Connie Hill |
Signed |
872 |
2024-01-26 10:28 |
Anonymous (not verified) |
94.188.205.177 |
Sole proprietor- Dennis R. Oliver dba Olivers Oasis Communications |
150 Spring Valley Ct. Springtown, TX 76082 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-26 |
Dennis Reeves Oliver |
doliversoasis@aol.com |
Springtown |
Parker |
Texas |
Helen Frances Steil |
John Kevin Steil |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dennis Reeves Oliver |
doliversoasis@aol.com |
Self |
Springtown |
Parker |
TX |
Helen Frances Steil |
John Kevin Steil |
Signed |
871 |
2024-01-26 09:16 |
Anonymous (not verified) |
94.188.205.168 |
NeX Level Restoration |
314 8th St NW, Cedar Rapids, IA, 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-26 |
Trevor McCauley |
jhawktm@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Bridget Camp |
Bridget Camp |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Trevor McCauley |
jhawktm@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Bridget Camp |
Bridget Camp |
Signed |
870 |
2024-01-26 07:57 |
Anonymous (not verified) |
94.188.207.228 |
Kodiak Group Security LLC |
1978 NW 92nd CT STE 2 Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-23 |
Howard Alton Johnston Jr |
howard@kodiakgroup.org |
Stuart |
Adair |
IA |
Joseph Crawford |
Howard Williams |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Howard Alton Johnston Jr |
howard@kodiakgroup.org |
Owner |
Stuart |
Adair |
Iowa |
Jospeh Crawford |
Howard Williams |
Signed |
869 |
2024-01-25 14:19 |
Anonymous (not verified) |
94.188.207.227 |
Christensen Leasing LLC |
1008 Brooks North Lane |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-25 |
Michael Christensen |
cconmichael@gmail.com |
Okoboji |
Dickinson |
Iowa |
Roger Christensen |
Dan Christensen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Christensen |
cconmichael@gmail.com |
Owner |
Okoboji |
Dickinson |
Iowa |
Roger Christensen |
Dan Christensen |
Signed |
868 |
2024-01-25 14:08 |
Anonymous (not verified) |
94.188.207.229 |
NeX Level Moving, LLC |
5634 Deerwood St. SW, Cedar Rapids, IA, 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-25 |
Trevor McCauley |
jhawktm@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Bridget |
Camp |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Trevor McCauley |
jhawktm@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Bridget Camp |
Trevor McCauley |
Signed |
867 |
2024-01-24 15:04 |
Anonymous (not verified) |
94.188.207.227 |
Shook Handyman |
2415 Plum Creek Rd |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-24 |
Nolan Shook |
office@shookhandyman.com |
Sioux City |
Woodbury |
IA |
McKenna Warner |
Jessica Shook |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Susan Geist |
sgeist@paychex.com |
Paychex Insurance Agency Inc |
Rochester |
Monroe |
NY |
Nolan Shook |
McKenna Warner |
Signed |
866 |
2024-01-23 14:40 |
Anonymous (not verified) |
94.188.207.225 |
Firm Foundation Concrete |
PO Box 164 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-23 |
Lyle Schut |
firmfoundationbros@gmail.com |
Sioux Center |
Sioux |
Iowa |
Erica Schut |
Miguel Perez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lyle Schut |
firmfoundationbros@gmail.com |
Owner |
Sioux Center |
Sioux |
IA |
Erica Schut |
Miguel Perez |
Signed |
865 |
2024-01-23 14:32 |
Anonymous (not verified) |
94.188.205.177 |
Josh Oswald |
505 Eisenhower Rd., Osceola, IA 50213 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-23 |
Joshua Oswald |
jjoswald47@gmail.com |
Osceola |
Clarke |
Iowa |
Douglas Eugene Miller |
Elaine Lee |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joshua Oswald |
jjoswald47@gmail.com |
Owner/Sole Proprietor |
Osceola |
Clarke |
Iowa |
Douglas Eugene Miller |
Elaine Lee |
Signed |
864 |
2024-01-23 14:31 |
Anonymous (not verified) |
94.188.207.230 |
Firm Foundation Concrete |
PO Box 164 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-23 |
Greg Schut |
firmfoundationbros@gmail.com |
Sioux Center |
Sioux |
Iowa |
Erica Schut |
Miguel Perez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Greg Schut |
firmfoundationbros@gmail.com |
Owner |
Sioux Center |
Sioux |
IA |
Erica Schut |
Miguel Perez |
Signed |
863 |
2024-01-23 13:59 |
Anonymous (not verified) |
94.188.205.176 |
United Marble & Tile, Inc. |
915 8th Street, #201, Boone, IA. 50036 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-24 |
Albert James Gotta |
jim@umtile.com |
Slater |
Boone |
IA |
Antonina M Gotta |
MARY KATE RUSSELL |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Albert James Gotta |
jim@umtile.com |
President Sole Share Holder |
Boone |
IA |
IA |
Antonina M Gotta |
Antonina M Gotta |
Signed |
862 |
2024-01-22 13:55 |
Anonymous (not verified) |
94.188.207.228 |
Emcubed Enterprises, Inc |
979 40th Ave, 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. |
2024-01-22 |
Bradley D Morrison |
brad@riverbendsignworks.com |
Moline |
Rock Island |
IL |
Richard Henning |
Kyle Sebben |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Morrison |
brad@riverbendsignworks.com |
Owner |
Moline |
Rock Island |
IL |
Richard Henning |
Kyle Sebben |
Signed |
861 |
2024-01-19 11:52 |
Anonymous (not verified) |
94.188.207.228 |
Nex level moving llc |
5634 Deerwood ST SW, Cedar Rapids, IA 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-19 |
Martavian |
mborseth0110@gmail.com |
Cedar rapids |
Linn |
Iowa |
Christine B. |
Jenny B. |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Martavian Borseth |
mborseth0110@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Christine B. |
Jenny B. |
Signed |
860 |
2024-01-19 08:59 |
Anonymous (not verified) |
94.188.205.168 |
T&R Drywall LLC |
1450 NE 69th Pl Ste 56 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. |
2024-01-19 |
Carmelo Chavez |
Special.t.d@hotmail.com |
Des Moines |
Polk |
Iowa |
Omar L Tippetts |
Omar L Tippetts Jr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
N/A |
special.t.d@hotmail.com |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
Signed |
859 |
2024-01-19 06:38 |
Anonymous (not verified) |
94.188.205.166 |
D & G Communications |
405 1st Street N. Farley, Iowa 52046 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-19 |
David William Hirsch |
dngcomm@hotmail.com |
Farley |
Dubuque |
Iowa |
Gina Hirsch |
Micki Jones |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dave Hirsch |
dngcomm@hotmail.com |
Owner |
Farley |
Dubuque |
Iowa |
Gina Hirsch |
Micki Jones |
Signed |
858 |
2024-01-18 08:24 |
Anonymous (not verified) |
94.188.207.226 |
Custom Flooring LLC |
7085 Bloomfield Road Lot 249 Des Moines, Iowa 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-18 |
Jesus Vera |
jesusvera199027@icloud.com |
Des Moines |
Polk |
Iowa |
Natalia Vera |
Adriana de Anda |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jesus Vera |
jesusvera199027@icloud.com |
Owner |
Des Moines |
Polk |
Iowa |
Natalia Vera |
Adriana de Anda |
Signed |
857 |
2024-01-17 16:04 |
Anonymous (not verified) |
94.188.205.167 |
GA Drywall LLC |
1906 West State Street Marshalltown Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-17 |
Oscar Vazquez LOPEZ |
gadrywall7@icloud.com |
Marshalltown |
Marshall |
Iowa |
Ana Ibarra |
Ana Lopez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Oscar Vazquez Lopez |
oscarlopez177@icloud.com |
Owner |
Marshalltown |
Marshall |
Iowa |
Ana Ibarra |
Ana Lopez |
Signed |
856 |
2024-01-17 15:09 |
Anonymous (not verified) |
94.188.205.167 |
Nex Level Moving, LLC |
5634 Deerwood Dr SW |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-17 |
LaPriest Green |
lapriestg@gmail.com |
Cedar Rapids |
Linn County |
Iowa |
Adam Feldmann |
LaPriest Green |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LaPriest Green |
lapriestg@gmail.com |
Employee |
Cedar Rapids |
Linn County |
Iowa |
Adam Feldmann |
LaPriest Green |
Signed |
855 |
2024-01-17 14:55 |
Anonymous (not verified) |
94.188.205.177 |
NexLevel Moving |
5634 Deerwood Dr Sw |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-17 |
LaPriest Green |
lapriestg@gmail.com |
Cedar Rapids |
Linn County |
Iowa |
Adam Feldmann |
LaPriest Green |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LaPriest Green |
lapriestg@gmail.com |
Employee |
Cedar Rapids |
Linn County |
Iowa |
Adam Feldmann |
LaPriest Green |
Signed |
854 |
2024-01-16 14:59 |
Anonymous (not verified) |
94.188.207.226 |
AJS Sanitation LLC |
504 Locust, St, PO Box 144, Minburn, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-16 |
Jason Mash |
jmash79@yahoo.com |
Minburn |
Dallas |
Iowa |
Don Richardson |
Abbey Luellen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jason Mash |
jmash79@yahoo.com |
President |
Minburn |
Dallas |
Iowa |
Don Richardson |
Abbey Luellen |
Signed |
853 |
2024-01-16 13:21 |
Anonymous (not verified) |
94.188.207.230 |
NeX Level Moving |
5634 Deerwood St SW Cedar Rapids, IA 52404 United States |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-16 |
Hayden Schaefer Wagner |
24haywag24@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Stephanie Allegra Wagner |
Hayden Schaefer Wagner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Hayden Schaefer Wagner |
24haywag24@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Hayden Schaefer Wagner |
Stephanie Allegra Wagner |
Signed |
852 |
2024-01-14 15:48 |
Anonymous (not verified) |
94.188.205.166 |
B St. Construction + Design, Inc. |
16 Southwest 42nd Street |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-14 |
Travis D Crouch |
trvscrouch@gmail.com |
Des Moines |
Iowa |
United States |
Jodi Essex |
Linda K Renze |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Travis D Crouch |
trvscrouch@gmail.com |
President |
Des Moines |
IA |
United States |
Jodi Essex |
Linda K Renze |
Signed |
851 |
2024-01-14 15:40 |
Anonymous (not verified) |
94.188.205.169 |
B St. Construction + Design, Inc. |
16 Southwest 42nd Street |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-13 |
Emily Renze-Crouch |
emily@bstdesigner.com |
Des Moines |
Iowa |
United States |
Jodi Essex |
Linda K Renze |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Emily Renze-Crouch |
emily@bstdesigner.com |
Vice President / CFO |
Des Moines |
IA |
United States |
Jodi Essex |
Linda K Renze |
Signed |
850 |
2024-01-11 15:22 |
Anonymous (not verified) |
94.188.205.167 |
CUB CONSTRUCTION LLC |
4243 GRANDVIEW AVE, DES MOINES, IOWA 50317 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-11 |
SUSANA MELENDEZ |
melendezsusana342@gmail.com |
Des Moines |
Polk |
Iowa |
Elsa Villanueva |
Jaime Leiva |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Susana Melendez |
melendezsusana342@gmail.com |
Owner |
Des Moines |
Pok |
Iowa |
Elsa Villanueva |
Jaime Leiva |
Signed |
849 |
2024-01-10 10:47 |
Anonymous (not verified) |
94.188.205.166 |
RedZone Football Academy LLC |
2000 James St. Suite 205, Coralville, IA 52241 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-10 |
Tyler James Blum |
blum.tyler@gmail.com |
Oxford |
Johnson |
Iowa |
Cole Davis |
Trevor Bollers |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tyler Blum |
redzonefbacademy@gmail.com |
same person, single member LLC/corp |
Oxford |
Johnson |
Iowa |
Cole Davis |
Trevor Bollers |
Signed |
848 |
2024-01-05 13:05 |
Anonymous (not verified) |
94.188.205.177 |
NeX Level Moving, LLC |
5634 Deerwood St. SW, Cedar Rapids, IA, 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-05 |
William J Feldmann |
feldmannwng@msn.com |
Anamosa |
Jones |
Iowa |
Bridget |
Camp |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William J Feldmann |
feldmannwng@msn.com |
Self |
Anamosa |
Jones |
Iowa |
Bridget |
Camp |
Signed |
847 |
2024-01-04 21:10 |
Anonymous (not verified) |
94.188.207.227 |
C & L Construction |
721 NE 60th St, 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. |
2024-01-04 |
Jose M Sanchez Melendez |
landerosmary@gmail.com |
Pleasant Hill |
Polk |
Iowa |
Marianna Landeros |
Cheryl Martinez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jose M Sanchez Melendez |
landerosmary@gmail.com |
Self |
Pleasant Hill |
Polk |
Iowa |
Marianna Landeros |
Cheryl Martinez |
Signed |
846 |
2024-01-03 14:13 |
Anonymous (not verified) |
94.188.205.168 |
Madison County Renovations Inc |
PO Box 521, Winterset, IA 50273 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-03 |
Jonathan Hays |
17jhays@gmail.com |
Waukee |
Dallas |
IA |
Rachel Anderson |
Roger Queck |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mark Hays |
mark.hays88@yahoo.com |
President |
Winterset |
Madison |
Iowa |
Rachel Anderson |
Roger Qyeck |
Signed |
845 |
2024-01-02 09:03 |
Anonymous (not verified) |
94.188.205.169 |
American Tree Service LLC |
416 S Kiel Street, Holstein, IA 51025 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-02 |
Austin Thevenot |
americantreeservice03@gmail.com |
Holstein |
Ida |
Iowa |
Jared Brashears |
Katie Gunkelman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Austin Thevenot |
americantreeservice03@gmail.com |
Owner |
Holstein |
Ida |
Iowa |
Jared Brashears |
Katie Gunkelman |
Signed |
844 |
2023-12-29 08:28 |
Anonymous (not verified) |
94.188.207.226 |
Emcubed Enterprises, Inc |
979 40th Ave, Bettendorf, IA 52722 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-29 |
Bradley David Morrison |
brad@riverbendsignworks.com |
Moline |
Rock Island |
IL |
David Rodriguez |
Lisbet Lule |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradley David Morrison |
brad@riverbendsignworks.com |
Owner |
Moline |
Rock Island |
IL |
David Rodriguez |
Lisbet Lule |
Signed |
843 |
2023-12-23 11:45 |
Anonymous (not verified) |
94.188.205.177 |
Janssen Handyman Service LLC |
503 Cherry Ave. Woodward, IA 50276 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-14 |
Cody A. Janssen |
janssenhandyman86@gmail.com |
Woodward |
Iowa |
Iowa |
Stephenie Janssen |
Glen Hall |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cody A. Janssen |
janssenhandyman86@gmail.com |
Owner |
Woodward |
Iowa |
Iowa |
Stephenie Janssen |
Glen Hall |
Signed |
842 |
2023-12-18 16:31 |
Anonymous (not verified) |
94.188.205.168 |
Brandon Clement |
3503 South Union St |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-18 |
Brandon Clement |
hawthornhill@paramark.us |
Des Moines |
Polk |
IA |
Brandi Haight |
Amanda Thompson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brandon Clement |
hawthornhill@paramark.us |
none |
Des Moines |
polk |
IA |
Brandi Haight |
Amanda Thompson |
Signed |
841 |
2023-12-18 16:28 |
Anonymous (not verified) |
94.188.205.168 |
Dennis Clement |
203 Astor St |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-18 |
Dennis Clement |
haight0929@gmail.com |
Des Moines |
Polk |
IA |
Amanda Thompson |
Brandi Haight |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dennis Clement |
haight0929@gmail.com |
none |
Des Moines |
polk |
IA |
Brandi Haight |
Amanda Thompson |
Signed |
840 |
2023-12-18 16:21 |
Anonymous (not verified) |
94.188.205.166 |
DC Painting Inc |
205 Astor St |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-18 |
Damion Clement |
amanda_thompson_marie@yahoo.com |
Des Moines |
polk |
IA |
Brandi Haight |
Amanda Thompson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Damion Clement |
amanda_thompson_marie@yahoo.com |
owner |
Des Moines |
Polk |
IA |
Brandi Haight |
Amanda Thompson |
Signed |
839 |
2023-12-18 16:12 |
Anonymous (not verified) |
94.188.207.227 |
515 Painting llc |
po box 157 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-18 |
Marvin S Parker JR |
stvpkr@gmail.com |
berwick |
polk |
iowa |
Christopher Eldridge |
Dillon Parker |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Marvin parker |
stvpkr@gmail.com |
owner |
berwick |
Polk |
Iowa |
Christopher Eldridge |
Dillon Parker |
Signed |
838 |
2023-12-14 08:57 |
Anonymous (not verified) |
94.188.207.223 |
Chuck Amling |
807 Main Street, Garber IA 52048 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-14 |
Chuck Amling |
mitzi@bruggemanlumber.com |
Garber |
IA |
United States |
Michelle Hoeger |
Roger Gibbs |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chuck Amling |
mitzi@bruggemanlumber.com |
Self |
Garber |
Clayton |
United States |
Michelle Hoeger |
Roger Gibbs |
Signed |
837 |
2023-12-13 08:51 |
Anonymous (not verified) |
94.188.207.228 |
J&M Tire and Repair LLC |
31006 Hedge Ave. |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-13 |
Jacob Mills Barkley |
jmtireandrepair@gmail.com |
Sioux city |
Plymouth |
Iowa |
Kevin Voth |
Evan Cook |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jacob Mills Barkley |
jmtireandrepair@gmail.com |
Owner |
Sioux City |
Plymouth |
Iowa |
Kevin Voth |
Evan Cook |
Signed |
836 |
2023-12-13 08:46 |
Anonymous (not verified) |
94.188.207.227 |
J&M Tire and Repair LLC |
31006 hedge ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-13 |
Macklin Paul Barkley |
barkley_mack@yahoo.com |
Merrill |
Plymouth |
Iowa |
Evan Cook |
Kevin Voth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Macklin Barkley |
jmtireandrepair@gmail.com |
Owner |
Merrill |
Plymouth |
Iowa |
Kevin Voth |
Evan Cook |
Signed |
835 |
2023-12-13 08:41 |
Anonymous (not verified) |
94.188.207.226 |
J&M Tire and Repair LLC |
31006 hedge 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. |
2022-12-13 |
Jacob Mills Barkley |
jmtireandrepair@gmail.com |
sioux city |
Iowa |
United States |
Evan Cook |
Kevin Vothj |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jacob Mills Barkley |
jmtireandrepair@gmail.com |
Owner |
sioux city |
Iowa |
United States |
Evan Cook |
Kevin Voth |
Signed |
834 |
2023-12-13 08:35 |
Anonymous (not verified) |
94.188.207.228 |
PHOENIX CONSTRUCTION LLC |
2219 E 13TH ST DES MOINES, IA 50316 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-13 |
JUAN PABLO GUTIERREZ LEON |
jpgutierrez9000@yahoo.com |
DES MOINES |
IA |
IA |
DAISY VASQUEZ |
GRACIELA RODRIGUEZ |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
ARTURO SALGADO |
commercial@aksinsurance.com |
Insured |
Irving |
TX |
TX |
DAISY VASQUEZ |
GRACIELA RODRIGUEZ |
Signed |
833 |
2023-12-12 07:31 |
Anonymous (not verified) |
94.188.207.224 |
Axe-cade LLC |
136 E Main Street Anamosa, IA 52205 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-12 |
Teresa Coons |
axecadeonmain@gmail.com |
Anamosa |
Iowa |
United States |
Chad Coons |
Bret Funke |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chad Coons |
ccoons03@gmail.com |
Member |
Anamosa |
Iowa |
United States |
Teresa Coons |
Bret Funke |
Signed |
832 |
2023-12-07 09:57 |
Anonymous (not verified) |
94.188.207.226 |
Andrew Garberson |
400 SW 42nd Street, Des Moines, IA 50312 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-07 |
Andrew Garberson |
andrew.garberson@gmail.com |
Des Moines |
Polk |
IA |
Jeanette Harris |
Emily Feriz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andrew Garberson |
andrew.garberson@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Jeanette Harris |
Emily Feriz |
Signed |
831 |
2023-12-06 17:04 |
Anonymous (not verified) |
94.188.205.167 |
PHOENIX CONSTRUCTION LLC |
2219 E 13th St Des Moines, IA 50316 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-02 |
JUAN PABLO GUTIERREZ LEON |
jpgutierrez9000@yahoo.com |
Des Moines |
IA |
IA |
DAISY VASQUEZ |
Graciela Rodriguez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
arturo salgado |
fortworth@aksinsurance.com |
insured |
irving |
TX |
TX |
DAISY VASQUEZ |
DAISY VASQUEZ |
Signed |
830 |
2023-12-03 18:42 |
Anonymous (not verified) |
94.188.205.167 |
Custom Decks, LLC |
5719 Washington Ave, Des Moines, IA 50310-1072 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-03 |
Charles Dean Oakley IV |
oakleyoutdoorsolutions@gmail.com |
Carlisle |
Warren |
Iowa |
Sharon Marie Bracelin |
Casey John Eaton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Charles Dean Oakley IV |
Oakleyoutdoorsolutions@gmail.com |
Owner |
Carlisle |
Warren |
Iowa |
Casey John Eaton |
Sharon Marie Bracelin |
Signed |
829 |
2023-11-27 08:59 |
Anonymous (not verified) |
94.188.207.224 |
Adam Ruess Masonry |
206.w Elm st |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-27 |
Adam Ruess |
ruess33@gmail.com |
Lone Tree |
IA |
United States |
Adam Ruess |
Adam Ruess |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam Ruess |
ruess33@gmail.com |
Owner |
Lone Tree |
IA |
United States |
Adam Ruess |
Adam Ruess |
Signed |
828 |
2023-11-22 10:39 |
Anonymous (not verified) |
94.188.207.229 |
T&R Drywall LLC |
1450 NE 69th Pl Ste 56 Ankeny, IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-22 |
Julio Cazares Ornelas |
Special.t.d@hotmail.com |
Des Moines |
Polk |
Iowa |
Omar L Tippetts |
Omar L Tippetts Jr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
N/A |
special.t.d@hotmail.com |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
Signed |
827 |
2023-11-22 10:30 |
Anonymous (not verified) |
94.188.205.169 |
T&R Drywall LLC |
1450 NE 69th Pl Ste 56 Ankeny, IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-22 |
Roberto Javier Rodriguez Perez |
Special.t.d@hotmail.com |
Waukee |
Dallas |
IA |
Omar L Tippetts |
Omar L Tippetts Jr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
N/A |
special.t.d@hotmail.com |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
Signed |
826 |
2023-11-22 08:04 |
Anonymous (not verified) |
94.188.207.226 |
Sabuydee Corporation |
617 Davis Ave. / Corning, IA 50841 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-22 |
Adam Grundman |
adamgrundman@gmail.com |
Corning |
Adams |
Iowa |
Carol Penglase |
MIchael Grundman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam Grundman |
adamgrundman@gmail.com |
President |
Corning |
Iowa |
United States |
Carol Penglase |
Michael Grundman |
Signed |
825 |
2023-11-22 08:02 |
Anonymous (not verified) |
94.188.207.224 |
Sabuydee Corporation |
617 Davis Ave. / Corning, IA 50841 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-22 |
Nantawan Grundman |
lakejournal@gmail.com |
Corning |
Adams |
Iowa |
Carol Penglase |
Michael Grundman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam Grundman |
adamgrundman@gmail.com |
President |
Corning |
Iowa |
United States |
Carol Penglase |
Michael Grundman |
Signed |
824 |
2023-11-21 13:22 |
Anonymous (not verified) |
94.188.207.227 |
OhZone. LLC |
852 Washington Street Burlington, IA 52601 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-19 |
Jeffery W Ishmael |
jeffishmael@gmail.com |
Des Moines |
IA |
United States |
Juan DeLlanos |
Gregory Gunter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffery W Ishmael |
jeffishmael@gmail.com |
Co-Owner |
Des Moines |
IA |
United States |
Juan DeLlanos |
Gregory Gunter |
Signed |
823 |
2023-11-20 14:04 |
Anonymous (not verified) |
94.188.205.169 |
CDNE, Inc. |
311 E. Alta Vistta Ave. |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-20 |
Craig Allen Payne |
Craig.Payne@indianhills.edu |
Ottumwa |
Wapello |
Iowa |
Erin Elizabeth Payne |
Nathan Thomas Payne |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Desirae Lynn Payne |
desip845@gmail.com |
Spouse |
Ottumwa |
Wapello |
Iowa |
Erin Elizabeth Payne |
Nathan Thomas Payne |
Signed |
822 |
2023-11-20 09:43 |
Anonymous (not verified) |
94.188.207.223 |
Lifeson LLC |
303 6th Ave Coralville IA 52241 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-14 |
Scott Parshall |
scott@lifeson.com |
Coralville |
Johnson |
Iowa |
Samantha Mlavsky |
Pamela Mahon |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott Parshall |
scott@lifeson.com |
member |
Coralville |
Johnson |
Iowa |
Samantha Mlavsky |
Pamela Mahon |
Signed |
821 |
2023-11-17 13:30 |
Anonymous (not verified) |
94.188.207.230 |
ABC LOCK INC. |
2209 2nd Ave S. P.O. Box 433 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-17 |
Dennis Diekhuis |
keyman@cltel.net |
Clear Lake |
United States |
Iowa |
Dennis Diekhuis |
Dennis Diekhuis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dennis Diekhuis |
keyman@cltel.net |
Owner |
Clear lake |
United States |
Iowa |
Dennis Diekhuis |
Dennis Diekhuis |
Signed |
820 |
2023-11-16 14:32 |
Anonymous (not verified) |
94.188.205.175 |
T&R Drywall LLC |
1450 NE 69th Pl Ste 56 Ankeny, IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-01 |
Jonathan Manzano |
Special.t.d@hotmail.com |
Des Moines |
Polk |
IA |
Omar L Tippetts |
Omar L Tippetts Jr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
N/A |
special.t.d@hotmail.com |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
Signed |
819 |
2023-11-16 14:25 |
Anonymous (not verified) |
94.188.205.167 |
T&R Drywall LLC |
1450 NE 69th Pl Ste 56 Ankeny, IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-16 |
Jorge Marquez Soto |
Special.t.d@hotmail.com |
Des Moines |
Polk |
IA |
Omar L Tippetts |
Omar L Tippetts Jr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
N/A |
special.t.d@hotmail.com |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
Signed |
818 |
2023-11-16 13:34 |
Anonymous (not verified) |
94.188.207.230 |
T&R Drywall LLC |
1450 NE 69th Pl Ste 56 Ankeny, IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-16 |
N/A |
Special.t.d@hotmail.com |
N/A |
N/A |
N/A |
N/A |
N/A |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Manuel Velazquez |
special.t.d@hotmail.com |
owner |
Des Moines |
Polk |
IA |
Omar L Tippetts |
Omar L Tippetts Jr |
Signed |
817 |
2023-11-15 15:25 |
Anonymous (not verified) |
94.188.205.175 |
MO VALLEY TACO INC |
1971 LINCOLN HWY MISSOURI VALLEY IA 51555 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-01 |
REBECCA ALVAREZ |
abelardosmexicanfresh7@gmail.com |
MISSOURI VALLEY |
HARRISON |
IA |
GONZALO MUNOZ |
SILVIA CHAVEZ |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
REBECCA ALVAREZ |
abelardosmexicanfresh7@gmail.com |
OWNER |
MISSOURI VALLEY |
HARRISON |
IA |
GONZALO MUNOZ |
SILVIA CHAVEZ |
Signed |
816 |
2023-11-15 15:22 |
Anonymous (not verified) |
94.188.205.166 |
MO VALLEY TACO INC |
1971 LINCOLN HWY MISSOURI VALLEY IA 51555 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-01 |
MARTIN ALVAREZ |
abelardosmexicanfresh7@gmail.com |
MISSOURI VALLEY |
HARRISON |
IA |
GONZALO MUNOZ |
SILVIA CHAVEZ |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
MARTIN ALVAREZ |
abelardosmexicanfresh7@gmail.com |
OWNER |
MISSOURI VALLEY |
HARRISON |
IA |
GONZALO MUNOZ |
SILVIA CHAVEZ |
Signed |
815 |
2023-11-14 13:42 |
Anonymous (not verified) |
94.188.207.224 |
SunsetSue, LLC |
240 Solomia Court, Peosta, IA 52068 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-14 |
Lori Sue Stewart |
lori@hrbcplus.com |
Peosta |
IA |
United States |
Mark R Stewart |
Danielle M Leibfried |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lori S Stewart |
lori@hrbcplus.com |
Self |
Peosta |
IA |
United States |
Mark R Stewart |
Danielle M. Leibfried |
Signed |
814 |
2023-11-14 13:11 |
Anonymous (not verified) |
94.188.207.225 |
NeX Level Moving, LLC |
5634 Deerwood St. SW, Cedar Rapids, IA, 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-14 |
Garrett Allen Reno |
garrettreno2001@gmail.com |
Tipton |
Cedar |
Iowa |
Bridget Camp |
Tarin Erenberger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Garrett Reno |
garrettreno2001@gmail.com |
Self |
Tipton |
Cedar |
Iowa |
Bridget Camp |
Tarin Erenberger |
Signed |
813 |
2023-11-14 13:00 |
Anonymous (not verified) |
94.188.207.226 |
NeX Level Moving, LLC |
5634 Deerwood St. SW, Cedar Rapids, IA, 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-14 |
Garrett Allen Reno |
garrettreno2001@gmail.com |
Tipton |
Cedar |
Iowa |
Bridget Camp |
Tarin Erenberger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tarin Erenberger |
tarin.nexlevelusa@gmail.com |
Operations Director |
Cedar Rapids |
Linn |
Iowa |
Bridget Camp |
Garrett Reno |
Signed |
812 |
2023-11-11 19:26 |
Anonymous (not verified) |
94.188.207.230 |
Bikes To You Inc |
921 Broad St. |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-11 |
Craig Cooper |
craig@bikestoyou.com |
Grinnell |
Poweshiek |
Iowa |
Dave Huff |
Marge Huff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Craig Cooper |
craig@bikestoyou.com |
President |
Grinnell |
Poweshiek |
Iowa |
Dave Hiff |
Marge Huff |
Signed |
811 |
2023-11-11 11:04 |
Anonymous (not verified) |
94.188.205.175 |
PJ Trucking Unlimited LLC |
2617 380th Ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-11 |
Peggy Jensen |
pegandhalj@gmail.com |
Farragut |
Fremont |
IA |
Darlene Carpenter |
Julie Marshall |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Peggy Jensen |
pegandhalj@gmail.com |
Member |
Farragut |
Fremont |
IA |
Darlene Carpenter |
Julie Marshall |
Signed |
810 |
2023-11-09 17:41 |
Anonymous (not verified) |
94.188.205.167 |
Chad Ripple's Painting LLC |
899 NW 45th Ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-09 |
Chad Ripple |
ia515@hotmail.com |
Des Moines |
Polk |
Iowa |
Ron Spurgeon |
Brandon Haus |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chad Ripple |
ia515@hotmail.com |
President |
Des Moines |
Polk |
Iowa |
Ron Spurgeon |
Brandon Haus |
Signed |
809 |
2023-11-08 09:47 |
Anonymous (not verified) |
94.188.207.229 |
GruntWorkz Wedling and Fab, Inc. |
15519 80th Ave Blue Grass, IA 52726 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-08 |
Brandon Joseph Fox |
GruntWorkzwelding@gmail.com |
Blue Grass |
Scott |
Iowa |
Amanda Dawn Fox |
Brandon Joseph Fox |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brandon Joseph Fox |
GruntWorkzwelding@gmail.com |
Same Person |
Blue Grass |
Scott |
Iowa |
Amanda Dawn Fox |
Brandon Joseph Fox |
Signed |
808 |
2023-11-08 07:37 |
Anonymous (not verified) |
94.188.207.229 |
Cush Comfort |
1225 e. River Dr STE 206 Davenport IA 52803 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-30 |
Chris Cushman |
ccushman82@gmail.com |
Milan |
IL |
United States |
Deena Maurus |
Jenna Ortberg |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christopher Cushman |
ccushman82@gmail.com |
Owner |
Milan |
IL |
United States |
Deena Maurus |
Jenna Ortberg |
Signed |
807 |
2023-11-07 11:25 |
Anonymous (not verified) |
94.188.205.167 |
Keokuk Termite & Pest Control, INC. |
P.O.Box 422 Keokuk, IA 52632 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-07 |
Marc Lee Floyd |
keokuktermite@gmail.com |
Keokuk |
Lee |
Iowa |
Kayla Joanne Tonkin |
Esther Mae Floyd |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Marc Lee Floyd |
keokuktermite@gmail.com |
Owner |
Keokuk |
Lee |
Iowa |
Kayla Joanne Tonkin |
Esther Mae Floyd |
Signed |
806 |
2023-11-06 13:52 |
Anonymous (not verified) |
94.188.205.168 |
Southeast Iowa behavioral Healthcare center |
101 north 12th keokuk ia |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-06 |
Kendall elder |
klelder48@gmail.com |
Keokuk |
Lee |
Iowa |
Kendall elder |
Darian Miller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tami elder |
telder@leximgtoncg.com |
Payroll |
Keokuk |
Lee |
Iowa |
Kendall elder |
Darian miller |
Signed |
805 |
2023-10-31 14:53 |
Anonymous (not verified) |
94.188.207.225 |
PJ Trucking Unlimited LLC |
2617 380th Ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-31 |
Peggy Jensen |
pegandhalj@gmail.com |
Farragut |
Fremont |
Iowa |
Julie Marshall |
Darlene Carpenter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Peggy Jensen |
pegandhalj@gmail.com |
Member |
Farragut |
US |
US |
Julie Marshall |
Darlene Carpenter |
Signed |
804 |
2023-10-31 13:04 |
Anonymous (not verified) |
94.188.207.226 |
NeX Level Restoration LLC |
314 8th ST NW, Cedar Rapids, IA 52405 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-31 |
Bobby Caldwell SR |
blc5000@msn.com |
Cedar Rapids |
Linn |
IA |
Adam Feldmann |
Tarin Tanner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bobby Caldwell |
blc5000@msn.com |
Self |
Cedar Rapids |
Linn |
IA |
Adam Feldmann |
Tarin Tanner |
Signed |
803 |
2023-10-25 08:37 |
Anonymous (not verified) |
94.188.205.166 |
CEM Businesses LLC |
608 Evergreen Cir NW Bondurant, IA 50035 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-25 |
Ryan Canales |
ryancanales44@gmail.com |
West Des Moines |
Polk |
Iowa |
Raelynn Aicher |
Cameron VanBuren |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Dane McDonald |
dane.mcdonald@stellar-solar.net |
Self |
Bondurant |
Polk |
Iowa |
Raelynn Aicher |
Cameron VanBuren |
Signed |
802 |
2023-10-25 08:34 |
Anonymous (not verified) |
94.188.205.174 |
CEM Businesses LLC |
607 evergreen cir nw Bondurant, IA 50035 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-10-25 |
Dustin Rudolph |
dmrudo@gmail.com |
Des Moines |
Polk |
Iowa |
Cameron VanBuren |
Raelynn Aicher |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dane McDonald |
dane.mcdonald@stellar-solar.net |
Self |
Bondurant |
Polk |
Iowa |
Cameron VanBuren |
Raelynn Aicher |
Signed |
801 |
2023-10-25 08:32 |
Anonymous (not verified) |
94.188.205.177 |
CEM Businesses LLC |
608 Evergreen Cir NW Bondurant, IA 50035 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-10-25 |
Dane McDonald |
danemcdonald2@gmail.com |
Bondurant |
Polk |
Iowa |
Raelynn Aicher |
Cameron VanBuren |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dane McDonald |
dane.mcdonald@stellar-solar.net |
Self |
Bondurant |
Polk |
Iowa |
Raelynn Aicher |
Cameron VanBuren |
Signed |
800 |
2023-10-23 07:40 |
Anonymous (not verified) |
94.188.207.228 |
Lucas construction inc |
1707 mondamin ave des moines , Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-23 |
Luis Arturo Martinez Lucas |
luiss_95@icloud.com |
Des Moines |
USA |
Iowa |
Cristian António Martínez Lucas |
Manuel canizales |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Luis Arturo Martinez Lucas |
luiss_95@icloud.com |
President |
Des Moines |
Usa |
Iowa |
Cristian António Martínez Lucas |
Manuel canizales |
Signed |
799 |
2023-10-20 11:28 |
Anonymous (not verified) |
94.188.205.169 |
JC Roofing |
2320 SE 17th Street Des Moines, IA 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-20 |
Jose Antonio Ayala Contreras |
josecontrerasroofing91@gmail.com |
Des Moines |
Polk |
Iowa |
Jessica Newton |
Tom Newton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jose Antonio Ayala Contreras |
josecontrerasroofing91@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Jessica Newon |
Tom Newton |
Signed |
798 |
2023-10-20 10:54 |
Anonymous (not verified) |
94.188.205.177 |
Connerley Construction Inc |
5915 4Th St. SW Cedar Rapids, Iowa 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-20 |
Allen Connerley |
betterrentalsbyconnerley@aol.com |
CEDAR RAPIDS |
Linn |
Iowa |
Nika Mefford |
Duane Anderson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Connerley Construction Inc |
Connerleyconstruction@gmail.com |
Owner |
Cedar Rapids |
Linn |
IA |
Nika Mefford |
Duane Anderson |
Signed |
797 |
2023-10-20 07:04 |
Anonymous (not verified) |
94.188.205.175 |
T&R Drywall LLC |
1450 NE 69th Pl Ste 56 Ankeny IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-20 |
Jose Castro |
special.t.d@hotmail.com |
Des Moines |
Polk County |
Iowa |
Omar Tippetts |
Omar Tippetts Jr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
N/A |
special.t.d@hotmail.com |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
Signed |
796 |
2023-10-18 14:34 |
Anonymous (not verified) |
94.188.205.177 |
Yarn Tree Designs Inc |
117 Alexander Ave, Ames, IA 50010 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-18 |
Larry R Johnson |
larry@yarntree.com |
Ames |
Story |
Iowa |
Megan Chriswisser |
Erica Lenig |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Larry R Johnson |
larry@yarntree.com |
VP |
Ames |
Story |
Iowa |
Megan Chriswisser |
Erica Lenig |
Signed |
795 |
2023-10-18 14:29 |
Anonymous (not verified) |
94.188.205.169 |
Yarn Tree Designs Inc |
117 Alexander Ave, Ames, IA 50010 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-18 |
Sarah Beth Johnson |
Beth@yarntree.com |
Ames |
Story |
Iowa |
Megan Chriswisser |
Erica Lenig |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Larry R Johnson |
larry@yarntree.com |
VP |
Ames |
Story |
Iowa |
Megan Chriswisser |
Erica Lenig |
Signed |
794 |
2023-10-18 08:21 |
Anonymous (not verified) |
94.188.205.177 |
J&M Tire and Repair |
31006 hedge ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-18 |
Macklin Paul Barkley |
flyingtank92@yahoo.com |
merrill |
Iowa |
United States |
Brandon Norris |
Alex Barkley |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Macklin Paul Barkley |
jmtireandrepair@gmail.com |
Owner |
sioux city |
Iowa |
United States |
Brandon Norris |
Alex Barkley |
Signed |
793 |
2023-10-18 08:18 |
Anonymous (not verified) |
94.188.205.168 |
J&M Tire and Repair |
31006 hedge ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-18 |
Jacob Mills Barkley |
jmtireandrepair@gmail.com |
sioux city |
Iowa |
United States |
Alex Barkley |
Victoria Barkley |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jacob Mills Barkley |
jmtireandrepair@gmail.com |
Owner |
sioux city |
Iowa |
United States |
Alex Barkley |
Victoria Barkley |
Signed |
792 |
2023-10-17 16:23 |
Anonymous (not verified) |
94.188.207.226 |
HEIMGARTNER INSURANCE INC |
26511 Hedge Ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-17 |
Gina Heimgartner |
travis.insure@gmail.com |
Merrill |
ia |
United States |
Malinda Short |
Scott Delperdang |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Travis Heimgartner |
travis.insure@gmail.com |
President |
Sioux City |
Iowa |
United States |
Malinda Short |
Scott Delperdang |
Signed |
791 |
2023-10-17 16:21 |
Anonymous (not verified) |
94.188.207.229 |
HEIMGARTNER INSURANCE INC |
26511 Hedge Ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-17 |
Travis Heimgarter |
travis.insure@gmail.com |
Merrill |
ia |
United States |
Malinda Short |
Scott Delperdang |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Travis Heimgarter |
travis.insure@gmail.com |
President |
Merrill |
ia |
United States |
Malinda Short |
Scott Delperdang |
Signed |
790 |
2023-10-17 14:16 |
Anonymous (not verified) |
94.188.205.166 |
Reform exteriors |
326 1st street mason city IA |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-16 |
Manuel g ramos |
ramosm943@gmail.com |
IA |
Cerro gordo |
Iowa |
Manuel ramos |
Manuel ramos |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Manuel g ramos |
ramosm943@gmail.com |
Owner |
Iowa |
Cerro gordo |
Iowa |
Manuel ramos |
Manuel ramos |
Signed |
789 |
2023-10-16 07:38 |
Anonymous (not verified) |
94.188.205.177 |
Aurora Aesthetics and Functional Medicine LLC |
713 1st 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. |
2023-10-04 |
Michael Friess |
Aurorafunctionalmed@gmail.com |
Mount Vernon |
IA |
United States |
Meagan Mclaughlin |
Stephanie Friess |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Stephanie Friess |
Aurorafunctionalmed@gmail.com |
Owner |
Mount Vernon |
Iowa |
United States |
Michael Friess |
Meagan Mclaughlin |
Signed |
788 |
2023-10-16 07:32 |
Anonymous (not verified) |
94.188.207.225 |
Aurora Aesthetics and Functional Medicine LLC |
713 1st 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. |
2023-10-04 |
Stephanie Friess |
Aurorafunctionalmed@gmail.com |
Mount Vernon |
IA |
United States |
Michael Friess |
Meagan Friess |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Friess |
mfriess1985@gmail.com |
business manager |
Mount Vernon |
Iowa |
IA |
Michael Friess |
Meagan Friess |
Signed |
787 |
2023-10-16 07:30 |
Anonymous (not verified) |
94.188.207.223 |
Aurora Aesthetics and Functional Medicine LLC |
713 1st 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. |
2023-10-04 |
Meagan Mclaughlin |
Aurorafunctionalmed@gmail.com |
Mount Vernon |
IA |
United States |
Stephanie Friess |
Michael Friess |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Friess |
Aurorafunctionalmed@gmail.com |
business manager |
Mount Vernon |
Iowa |
United States |
Meagan Mclaughlin |
Stephanie Friess |
Signed |
786 |
2023-10-16 07:27 |
Anonymous (not verified) |
94.188.207.230 |
Aurora Aesthetics and Functional Medicine LLC |
713 1st 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. |
2023-10-04 |
Meagan Mclaughlin |
meagan.vitae@gmail.com |
Mount Vernon |
IA |
United States |
Michael Friess |
Stephanie Friess |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Friess |
Aurorafunctionalmed@gmail.com |
business manager |
Mt Vernon |
IA |
United States |
Stephanie Friess |
Meagan Friess |
Signed |
785 |
2023-10-10 15:42 |
Anonymous (not verified) |
94.188.207.228 |
KO pest solutions LLC |
1208 s zenith ave davenport iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-10 |
Jesus Correa Jr |
k.o.pestcontrol@outlook.com |
davenport |
Scott |
Iowa |
Jesus Correa Jr |
Jesus Correa Jr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jesus correa Jr |
k.o.pestcontrol@outlook.com |
owner |
Davenport |
Scott |
iowa |
Jesus correa |
Jesus Correa |
Signed |
784 |
2023-10-09 13:09 |
Anonymous (not verified) |
94.188.205.177 |
SEHIC G&S LLC |
4201 62nd st apt 4 Urbandale Iowa 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. |
2023-10-09 |
Bajro Sehic |
kalesija20@gmail.com |
Urbandale |
Polk |
Iowa |
Bajro sehic |
Bajro sehic |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bajro sehic |
kalesija20@gmail.com |
Owner |
Urbandale |
Polk |
Iowa |
Bajro sehic |
Bajro Sehic |
Signed |
783 |
2023-10-06 11:08 |
Anonymous (not verified) |
94.188.207.223 |
Hawkeye Construction and Snow Removal |
3581 Perch Drive SE, Unit C, Iowa City, Iowa 52240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-06 |
Mark Phelps |
maintenance@hawkeyecampus.com |
Iowa City |
Johnson |
Iowa |
Elizabeth Phelps |
Alexandra Phelps |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mark Phelps |
maintenance@hawkeyecampus.com |
owner |
Iowa City |
Johnson |
Iowa |
Elizabeth Phelps |
Alexandra Phelps |
Signed |
782 |
2023-10-05 09:40 |
Anonymous (not verified) |
94.188.207.226 |
Haes Floorcovering |
2282 290th st. New London, Ia 52645 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-05 |
John Haes |
floorman.0742@yahoo.com |
New London |
US |
Iowa |
Miranda Haes |
Tom Haes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John Haes |
floorman.0742@yaoo.com |
Owner |
New London |
US |
Iowa |
Miranda Haes |
Tome Haes |
Signed |
781 |
2023-10-05 08:14 |
Anonymous (not verified) |
94.188.205.167 |
T&R Drywall LLC |
1450 NE 69th Pl Ste 56 Ankeny IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-05 |
Juaquin Lopez Gutierrez |
special.t.d@hotmail.com |
Des Moines |
Polk County |
Iowa |
Omar Tippetts |
Omar Tippetts Jr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
N/A |
special.t.d@hotmail.com |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
Signed |
780 |
2023-10-04 16:18 |
Anonymous (not verified) |
94.188.207.228 |
Premier Staffing Agency |
6887 Dakota drive West Desmoines Iowa 50266 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-10 |
Felistas Kimani |
mwangifelistas4@gmail.com |
West Desmoines |
Dallas |
Iowa |
Denis Waweru |
George Komu |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Felistas Kimani |
mwangifelistas4@gmail.com |
member |
West Desmoines |
Dallas |
Iowa |
Denis Waweru |
George Komu |
Signed |
779 |
2023-10-04 07:14 |
Anonymous (not verified) |
94.188.207.225 |
CanD Homes, LLC |
1147 Leitha Ter, Waverly, IA 50677 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-04 |
Alexander Eckard-Lewis |
alex.lewis@candhomes.com |
Waverly |
Bremer |
IA |
Connor Eustice |
Victor Sanders |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Alexander Eckard-Lewis |
alex.lewis@candhomes.com |
Vice President |
Waverly |
Bremer |
IA |
Connor Eustice |
Victor Sanders |
Signed |
778 |
2023-10-02 10:15 |
Anonymous (not verified) |
94.188.205.166 |
Medinas Tile |
2365 267th Street Oskaloosa, Iowa 52577 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-02 |
Leon Medinas |
elleonmedina@hotmail.com |
Oskaloosa |
Mahaska |
Iowa |
Rocio Medinas |
Manuel Lopez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Leon Medina |
elleonmedina@hotmail.com |
Owner |
Oskaloosa |
Mahaska |
Iowa |
Rocio Medina |
Manuel Lopez |
Signed |
777 |
2023-10-02 08:50 |
Anonymous (not verified) |
94.188.205.176 |
Alexandria Munro |
7020 Forest Drive, Johnston, IA 50131 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-02 |
Alexandria Munro |
armunro17@gmail.com |
Johnston |
Polk |
Iowa |
John Goodhue |
Miranda Cyr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Alexandria Munro |
armunro17@gmail.com |
Owner |
Johnston |
Polk |
Iowa |
John Goodhue |
Miranda Cyr |
Signed |
776 |
2023-10-02 07:19 |
Anonymous (not verified) |
94.188.205.176 |
Silver Fox Construction |
1238 71st |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-02 |
Scott Klinkefus |
scott.klinkefus@gmail.com |
Windsor Heights |
Iowa |
United States |
Kristin Brantley |
Matt Jones |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott Klinkefus |
scott.klinkefus@gmail.com |
Same |
Windsor Heights |
Iowa |
United States |
Kristin Brantley |
Matt Jones |
Signed |
775 |
2023-10-01 10:35 |
Anonymous (not verified) |
94.188.205.169 |
Prem Krishnan Menon Mohan Kumar |
460 NW Gracewood Dr, 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. |
2023-10-01 |
Prem Krishnan Menon Mohan Kumar |
premkrishnan@gmail.com |
Waukee |
Dallas |
Iowa |
Dileep Vasudevan |
Roy Shashidharan |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Prem Krishnan Menon Mohan Kumar |
premkrishnan@gmail.com |
Owner |
Waukee |
Dallas |
Iowa |
Dileep Vasudevan |
Roy Shashidharan |
Signed |
774 |
2023-09-21 10:21 |
Anonymous (not verified) |
94.188.205.167 |
Tri State Trucking LLC |
47282 US Hwy 20 Atkinson, NE 68713 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-09-21 |
Casey Schaaf |
casey@tri-statetrucking.com |
Atkinson |
Holt |
NE |
Angela Schaaf |
Crystal Osborne |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Casey Schaaf |
casey@tri-statetrucking.com |
Owner |
Atkinson |
Holt |
NE |
Angela Schaaf |
Crystal Osborne |
Signed |