570 |
2022-11-16 10:35 |
Anonymous (not verified) |
50.81.253.108 |
XU's Golden Dragon |
508 Chestnut St., Atlantic, IA 50022 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-11-16 |
Xu Long |
125529647@QQ.COM |
Atlantic |
Cass |
IA |
Richard Crall |
Shannon Crall |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Richard Crall |
richard@partnersins.com |
Insurance Agent |
Atlantic |
Cass |
United States |
Shannon Crall |
Richard Crall |
Signed |
571 |
2022-11-16 10:40 |
Anonymous (not verified) |
50.81.253.108 |
XU's Golden Dragon |
508 Chestnut St., Atlantic, IA 50022 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-11-16 |
Tingjie Huang |
125529647@QQ.COM |
Atlantic |
Cass |
IA |
Richard Crall |
Shannon Crall |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Richard Crall |
richard@partnersins.com |
Insurance Agent |
Atlantic |
Cass |
United States |
Shannon Crall |
Richard Crall |
Signed |
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 |
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 |
267 |
2021-05-24 11:25 |
Anonymous (not verified) |
70.168.33.178 |
Town and Country Aqua Club |
22687 James Dr, council bluffs, IA 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. |
2021-05-24 |
Cheri Smith |
3smithathome@cox.net |
Council Bluffs |
Pottawattamie |
IA |
Mark Smith |
Kirstyn Smith |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cheri Smith |
3smithathome@cox.net |
Secretary |
Council Bluffs |
Pottawattamie |
IA |
Mark Smith |
Kirstyn Smith |
Signed |
616 |
2023-03-02 13:32 |
Anonymous (not verified) |
94.188.207.229 |
Kevin Pritchard |
126 S Main St, Dundee IA 52038 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-02 |
Kevin Pritchard |
486@gmail.com |
Dundee |
Delaware |
Iowa |
Mitzi Hoeger |
Roger Gibbs |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kevin Pritchard |
486@gmail.com |
Self |
Dundee |
Delaware |
Iowa |
Mitzi Hoeger |
Roger Gibbs |
Signed |
366 |
2021-11-23 12:20 |
Anonymous (not verified) |
173.19.234.191 |
Brezina Homes, Inc |
9008 NW 73rd Place, 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. |
2021-11-23 |
Allen J. Brezina |
a.brezina@mchsi.com |
Johnston |
Polk |
Iowa |
Christopher Winterboer |
Melissa Winterboer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Allen J. Brezina |
a.brezina@mchsi.com |
President |
Johnston |
Polk |
Iowa |
Christopher Winterboer |
Melissa Winterboer |
Signed |
367 |
2021-11-23 12:23 |
Anonymous (not verified) |
173.19.234.191 |
Brezina Homes, Inc |
9008 NW 73rd Place, 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. |
2021-11-23 |
Monica M. Brezina |
a.brezina@mchsi.com |
Johnston |
Polk |
Iowa |
Christopher Winterboer |
Melissa Winterboer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Allen J. Brezina |
a.brezina@mchsi.com |
President |
Johnston |
Polk |
Iowa |
Christopher Winterboer |
Melissa Winterboer |
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 |
395 |
2022-01-31 15:49 |
Anonymous (not verified) |
75.89.77.218 |
Mind Body Soul 22, Inc. |
101 South St. Delhi, IA 52223 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-31 |
Abby Paige DeGroot |
abby.whittenbaugh@gmail.com |
Delhi |
Deleware |
Iowa |
Kaes Christian DeGroot |
Michael David Whittenbaugh |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Abby Paige DeGroot |
abby@mbs22.com |
President |
Delhi |
Deleware |
Iowa |
Kaes Christian DeGroot |
Michael David Whittenbaugh |
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 |
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 |
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 |
537 |
2022-09-20 09:01 |
Anonymous (not verified) |
173.20.206.50 |
Accent Painting LLC |
613 Locust ST |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-09-20 |
Anthony Gilbert Gasco |
accentpainting@yahoo.com |
La Porte City |
Blackhawk |
Iowa |
Arthur Rudolf Gasco |
Aurora Jealee Gasco |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Anthony Gilbert Gasco |
accentpainting@yahoo.com |
Owner |
La Porte City |
Blackhawk |
Iowa |
Arthur Rudolf Gasco |
Aurora Jealee Gasco |
Signed |
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 |
568 |
2022-11-15 08:23 |
Anonymous (not verified) |
174.215.243.6 |
Cesar rolando Acosta rivera |
2080 king ave apt 21 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. |
2022-11-15 |
Cesar rolando Acosta Rivera |
acostariveracesarrolando@gmail.com |
Des Moines Iowa |
Polk |
Iowa |
Juan acosta |
Antonio acosta |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cesar rolando Acosta Rivera |
acostariveracesarrolando@gmail.com |
Owner |
Des moines |
Polk |
Iowa |
Juan acosta |
Antonio acosta |
Signed |
569 |
2022-11-15 08:23 |
Anonymous (not verified) |
174.215.243.6 |
Cesar rolando Acosta rivera |
2080 king ave apt 21 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. |
2022-11-15 |
Cesar rolando Acosta Rivera |
acostariveracesarrolando@gmail.com |
Des Moines Iowa |
Polk |
Iowa |
Juan acosta |
Antonio acosta |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cesar rolando Acosta Rivera |
acostariveracesarrolando@gmail.com |
Owner |
Des moines |
Polk |
Iowa |
Juan acosta |
Antonio acosta |
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 |
711 |
2023-07-24 12:04 |
Anonymous (not verified) |
94.188.205.176 |
HAIGH & ESPE LIMITED |
1198 GRAND AVE, MARION, IA 52302 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-07-24 |
LYNN M. HAIGH |
ADAMSTILEANDSTONE@GMAIL.COM |
Cedar Rapids |
Linn |
Iowa |
DAVID REIBSAMEN |
STACEY ROGERS |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LYNN M. HAIGH |
ADAMSTILEANDSTONE@GMAIL.COM |
CORP. SECRETARY |
CEDAR RAPIDS |
LINN |
IOWA |
DAVID REIBSAMEN |
STACEY ROGERS |
Signed |
505 |
2022-06-30 17:20 |
Anonymous (not verified) |
209.180.36.109 |
Sani Enterprise |
101 Ashworth 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. |
2022-06-30 |
Admir Dogic |
adoydogic@gmail.com |
Urbandale |
polk |
iowa |
Sandro Tadic |
Andy Swanson |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Sandro Tadic |
sanienterprise14@gmail.com |
Owner |
Urbandale |
polk |
iowa |
Sandro Tadic |
Andy Swanson |
Signed |
247 |
2021-04-27 09:35 |
Anonymous (not verified) |
207.191.206.210 |
United windows and siding |
4080 1st Avenue NE, Cedar Rapids Iowa 52402 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2021-04-27 |
Adrian Sanchez |
adrian@unitedwindowsandsiding.com |
Aurora |
CO |
United States |
Megan Bierley |
Ginger Berens |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Adrian Sanchez |
adrian@unitedwindowsandsiding.com |
Owner |
Aurora |
Jeffereson |
CO |
Megan Bierley |
Ginger Berens |
Signed |
728 |
2023-08-03 12:28 |
Anonymous (not verified) |
94.188.205.166 |
Advanced Plumbing LLC |
2538 Carbide Ln, 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. |
2023-08-03 |
James O'Shea |
advancedplumbing1@yahoo.com |
Keokuk |
Iowa |
United States |
Rebecca O'Shea |
Tate O'Shea |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James O'Shea |
advancedplumbing1@yahoo.com |
Partner |
Keokuk |
Iowa |
United States |
Rebecca O'Shea |
Tate O'Shea |
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 |
499 |
2022-06-22 03:40 |
Anonymous (not verified) |
64.251.168.116 |
VALBURG AERIAL SPRAYING INC. |
27656 SD Hwy 44 WHITE RIVER SD 57579 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-19 |
Dan A Valburg |
agflyer620@gwtc.net |
White River |
SD |
SD |
LANDON HOSSLE |
JOSH HICKS |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dan A Valburg |
agflyer620@gwtc.net |
PRESIDENT |
White River |
SD |
SD |
LANDON HOSSLE |
JOSH HICKS |
Signed |
699 |
2023-06-21 14:04 |
Anonymous (not verified) |
94.188.205.166 |
WRS Inc |
5225 NE 17th St. 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. |
2023-06-21 |
Kevin A Alderman |
alderman@wrsia.com |
Urbandale |
Iowa |
United States |
John Kaldenberg |
Ronda Perry |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kevin Alderman |
alderman@wrsia.com |
President / Owner |
Urbandale |
Iowa |
United States |
John Kaldenberg |
Ronda Perry |
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 |
557 |
2022-10-17 09:23 |
Anonymous (not verified) |
67.22.198.94 |
Baker Irrigation Inc. |
2621 310th St. Rock Valley, IA 51247 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-10-17 |
Alex DeJager |
alex@bakerirrigationia.com |
Rock Valley |
Sioux |
Iowa |
Jesse Niemeyer |
Herlan DeJager |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Alex DeJager |
alex@bakerirrigationia.com |
Co-Owner |
Rock Valley |
Sioux |
Iowa |
Jesse Niemeyer |
Herlan DeJager |
Signed |
242 |
2021-04-21 13:27 |
Anonymous (not verified) |
198.14.211.149 |
Centerville Greenhouses |
418 N. 5th Street |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-21 |
Alexander Joseph Lind |
alex@centervillegreenhouses.com |
Centerville |
IA |
United States |
John Douglas Hurley |
Dennis James Peters |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Peter Michael Lind |
peter@centervillegreenhouses.com |
President |
Centerville |
IA |
United States |
John Douglas Hurley |
Dennis James Peters |
Signed |
438 |
2022-03-29 16:28 |
Anonymous (not verified) |
209.180.36.109 |
Sani Enterprise |
101 Ashworth 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. |
2022-03-29 |
Azmir Alic |
ale_boss00@hotmail.com |
Urbandale |
polk |
iowa |
Azmir Alic |
Andrew Swanson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andrew Swanson |
sanienterprise14@gmail.com |
Director of Operations |
Granger |
Dallas |
Iowa |
Andrew Swanson |
Sandro Tadic |
Signed |
580 |
2022-12-09 11:20 |
Anonymous (not verified) |
74.84.79.78 |
Aaron Alley |
101 Teale St. Davis City, IA 50065 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-01 |
Aaron Alley |
alleyre@hotmail.com |
Davis City |
Decatur |
Iowa |
Michael O'Conner |
Ron Rand |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Aaron Alley |
alleyre@hotmail.com |
owner |
Davis City |
Decatur |
Iowa |
Michael O'Conner |
Ron Rand |
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 |
978 |
2024-05-08 13:47 |
Anonymous (not verified) |
94.188.205.174 |
Meridian Logistics, LLC |
5249 N Park Pl NE, Unit #2060, 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. |
2024-05-07 |
Abigail Matthews |
almsolutions2021@gmail.com |
Chicago |
Cook |
IL |
Gayle Matteson |
Jane Calvert |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Abigail Matthews |
almsolutions2021@gmail.com |
Owner |
Chicago |
Cook |
IL |
Gayle Matteson |
Jane Calvert |
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 |
200 |
2021-03-03 17:33 |
Anonymous (not verified) |
172.58.84.30 |
Amee Ann Pepperson |
1536 1/2 W Locust |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-03 |
Amee Ann Pepperson |
amee0818@yahoo.com |
Davenport |
Scott |
Iowa |
Philip Gerald Hoxsey |
Michael Wayne Underdahl |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Amee A Pepperson |
amee0818@yahoo.com |
Self |
Davenport |
Scott |
Iowa |
Michael Wayne Underdahl |
Philip Gerald Hoxsey |
Signed |
646 |
2023-03-31 13:58 |
Anonymous (not verified) |
94.188.205.168 |
American Residential Services Inc |
1683 Elizabeth Dr Marion IA 52302 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-31 |
Robert Rettmann |
americanres@yahoo.com |
Apple Valley |
Dakota |
MN |
Nancy Rettmann |
William Dilts |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Rettmann |
americanres@yahoo.com |
President |
Apple Valley |
Dakota |
MN |
Nancy Rettmann |
William Dilts |
Signed |
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 |
150 |
2020-12-31 15:00 |
Anonymous (not verified) |
216.81.153.249 |
S&A Holdings LLC |
115 N 2nd Street, Fort Dodge, IA 50501 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-21 |
Amritpal Singh |
amritaust1@gmail.com |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Amritpal Singh |
amritaust1@gmail.com |
Owner |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
338 |
2021-09-22 10:34 |
Anonymous (not verified) |
216.81.153.249 |
APS LLC |
904 Lake Avenue |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-22 |
Amrit Singh |
amritaust1@gmail.com |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Amrit Singh |
amritaust1@gmail.com |
Owner |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
993 |
2024-05-17 13:05 |
Anonymous (not verified) |
94.188.205.176 |
Anacleto Campos Rojas |
7 North Street Hartford, Iowa 50118 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-17 |
Anacleto Campos Rojas |
anacletocampos1@icloud.com |
Hartford |
Warren |
Iowa |
Benjamin Campos Rojas |
Ezequiel Campos Rojas |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Anacleto Campos Rojas |
anacletocampos1@icloud.com |
Owner |
Hartford |
Warren |
Iowa |
Benjamin Campos Rojas |
Ezequiel Campos Rojas |
Signed |
75 |
2020-04-29 11:07 |
Anonymous (not verified) |
107.77.206.22 |
ACR Construction, Inc |
7330 NW 21 St. Ankeny, IA 50023 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-29 |
Andre Sean Drost |
andre.drost@acr-construction-inc.com |
Ankeny |
Polk |
IA |
Heidi Smith |
Jeff Smith |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Candace Drost |
acrdrost@hotmail.com |
President |
Ankeny |
Polk |
IA |
Heidi Smith |
Jeff Smith |
Signed |
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 |
227 |
2021-04-02 09:58 |
Anonymous (not verified) |
207.177.7.191 |
GOETTSCH DISPATCH INC |
200 MAIN ST GALVA, IA 51020 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-15 |
ANDREW GOETTSCH |
andygoettsch@gmail.com |
Galva |
Ida |
Iowa |
Kristy Dewey |
Terri Ullrich |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andrew Goettsch |
andygoettsch@gmail.com |
President |
Galva |
Ida |
Iowa |
Kristy Dewey |
Terri Ullrich |
Signed |
475 |
2022-05-19 10:11 |
Anonymous (not verified) |
172.86.13.54 |
BOLT HOLDINGS Inc. and Holt Precision dba Holt Bladeworks and Holt Kinetic Solutions |
3230 N. Center Point Rd Unit 204, Marion, IA 52302 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-19 |
Angey Holt |
Angey@Holtkineticsolutions.com |
Robins |
Linn |
Iowa |
Lisa Gleason |
Danielle Congleton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa Gleason |
Lisa@holtkineticsolutions.com |
General Manager |
Marion |
Linn |
Iowa |
Danielle Congleton |
Joe Holt |
Signed |
130 |
2020-11-02 12:40 |
Anonymous (not verified) |
67.55.220.86 |
Little Bison Childcare Center |
404 2nd St NW, Buffalo Center, IA 50424 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-11-02 |
Joseph Robert Angstman |
angstman.joe@gmail.com |
Buffalo Center |
Winnebago |
Iowa |
Emily Jean Thomsen Angstman |
Pamela Kay Angstman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph Robert Angstman |
angstman.joe@gmail.com |
Secretary |
Buffalo Center |
Winnebago |
Iowa |
Emily Jean Thomsen Angstman |
Pamela Kay Angstman |
Signed |
79 |
2020-05-06 08:14 |
Anonymous (not verified) |
97.125.243.140 |
pro plumbing and heating llc |
903 nw 37th ct ankeny iowa 50023 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-05-06 |
lee d kearney |
ankenypro@gmail.com |
ankeny |
polk |
iowa |
sheila m kearney |
keegan l kearney |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
lee d kearney |
ankenypro@gmail.com |
owner |
ankeny |
IA |
United States |
sheila m kearney |
keegan l kearney |
Signed |
645 |
2023-03-31 08:55 |
Anonymous (not verified) |
94.188.205.166 |
3Fitt Life, Inc. |
28345 Highway 52, Bellevue, IA 52031 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-31 |
Ann L Wachtel |
annw@3fitt.com |
Bellevue |
Jackson |
Iowa |
Jeff Laban |
Katie Laban |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ann L Wachtel |
annw@3fitt.com |
President |
Bellevue |
Jackson |
Iowa |
Jeff Laban |
Katie Laban |
Signed |
585 |
2022-12-15 20:32 |
Anonymous (not verified) |
192.110.196.132 |
Maywood Enterprises, Inc. |
28345 Highway 52, Bellevue, IA 52031 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-12-15 |
Ann L Wachtel |
annw@financepro123.com |
Bellevue |
Jackson |
Iowa |
Katie Laban |
Jeffrey Laban |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ann L Wachtel |
annw@financepro123.com |
President |
Bellevue |
Jackson |
IA |
Katie Laban |
Jeffrey Laban |
Signed |
185 |
2021-02-23 15:16 |
Anonymous (not verified) |
173.29.151.168 |
TONY V'S PAINTING |
2316 CRESCENT AVE 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. |
2021-02-23 |
ANTHONY VANCE |
ANTHONYJV1977@GMAIL.COM |
DAVENPORT |
SCOTT |
IA |
TONY BURKHART |
RICHARD MILLER-VANCE |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
ANTHONY VANCE |
ANTHONYJV1977@GMAIL.COM |
OWNER |
DAVENPORT |
SCOTT |
IA |
TONY BURKHART |
RICHARD MILLER-VANCE |
Signed |
529 |
2022-09-01 13:53 |
Anonymous (not verified) |
72.131.73.148 |
Sozo Companies, Inc. |
23751 Hoover Road, Warren MI 48089 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-09-01 |
Aaron Rasty |
arasty@sozocompanies.com |
Austin |
Travis |
Texas |
Robert Davis |
Paul Huth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Aaron Rasty |
arasty@sozocompanies.com |
President |
Austin |
Travis |
Texas |
Robert Davis |
Paul Huth |
Signed |
564 |
2022-11-12 13:05 |
Anonymous (not verified) |
152.117.104.212 |
ArborSharp Tree Care LLC |
125 South Russell Ave Ames IA 50010 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-11-12 |
Jonathan Michael Ostermann |
arborsharptc@gmail.com |
Ames |
IA |
IA |
Ben Wyatt |
Marc McClanahan |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jonathan Ostermann |
arborsharptc@gmail.com |
owner |
Ames |
story |
IA |
Ben Wyatt |
Marc McClanahan |
Signed |
689 |
2023-06-19 07:31 |
Anonymous (not verified) |
94.188.207.228 |
Nenger Argueta |
1317 5th Avenue 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. |
2023-06-19 |
Nenger Argueta |
arguetanenger30@gmail.com |
Des Moines |
Polk |
Iowa |
Gelbar Argueta |
Grace Argueta |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nenger Argueta |
arguetanenger30@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Gelbar Argueta |
Grace Argueta |
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 |
350 |
2021-10-25 08:22 |
Anonymous (not verified) |
208.95.64.3 |
Ron Sexton Construction Inc, |
1184 Vine Ave, Riverside IA 52327 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-27 |
Ronald R Sexton |
ashmac@iowatelecom.net |
Riverside |
Washington |
IA |
Greg Martin |
Michele McMichael |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ronald R Sexton |
ashmac@iowatelecom.net |
President |
Riverside |
Washington |
IA |
Greg Martin |
Michele McMichael |
Signed |
351 |
2021-10-25 08:24 |
Anonymous (not verified) |
208.95.64.3 |
Ron Sexton Construction Inc, |
1184 Vine Ave, Riverside IA 52327 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-27 |
Theresa A Sexton |
ashmac@iowatelecom.net |
Riverside |
Washington |
IA |
Greg Martin |
Michele McMichael |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Theresa A Sexton |
ashmac@iowatelecom.net |
VP, Secretary, Treasurer |
Riverside |
Washington |
IA |
Greg Martin |
Michele McMichael |
Signed |
904 |
2024-02-28 06:52 |
Anonymous (not verified) |
94.188.205.167 |
Monarca General Builders LLC. |
551 Martin Rd Waterloo Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-28 |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
President |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
905 |
2024-02-28 11:47 |
Anonymous (not verified) |
94.188.207.228 |
Monarca General Builders LLC |
551 Martin Rd Waterloo Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-01 |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
Presidente |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
353 |
2021-11-04 11:41 |
Anonymous (not verified) |
108.58.173.242 |
ASTL Moving And Storage Inc |
9530 FM 2920 #227 Tomball TX 77375 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-11-04 |
Peter Allen III |
astlmoving@yahoo.com |
Tomball |
Harris |
TX |
Peggi Makofka |
Yoel Taran |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Peter Allen III |
astlmoving@yahoo.com |
owner |
Tomball |
Harris |
TX |
Peggi Makofka |
Yoel Taran |
Signed |
733 |
2023-08-09 10:22 |
Anonymous (not verified) |
94.188.207.230 |
Atcher Service LLC |
145 Fremont Street, Hartford, IA 50118 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-08 |
Daniel J Love |
atcherservicetowing@gmail.com |
Hartford |
Warren |
Iowa |
Mandy Love |
Michael Love |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mandy Love |
dlovem2002@gmail.com |
owner |
Hartford |
Warren |
Iowa |
Dan Love |
Michael Love |
Signed |
374 |
2021-12-17 08:19 |
Anonymous (not verified) |
69.63.16.2 |
AT Construction Inc. |
5 Westview Acres NE, 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. |
2021-12-17 |
Tomas Acas |
atconstruction@hotmail.com |
Iowa City |
Johnson |
Iowa |
Steve Fishman |
Dyan Kriener |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tomas Acas |
atconstruction@hotmail.com |
President |
Iowa City |
Johnson |
Iowa |
Steve Fishman |
Dyan Kriener |
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 |
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 |
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 |
526 |
2022-08-17 11:16 |
Anonymous (not verified) |
173.27.233.86 |
Bradens Roofing and Construction Llc |
2450 Hart 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. |
2022-08-17 |
Arsenio Vargas Velazquez |
avargas409@gmail.com |
Des Moines |
polk |
Iowa |
Julissa Dionicio |
Jennifer Dionicio |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Arsenio Vargas Velazquez |
avargas409@gmail.com |
owner |
Des Moines |
Polk |
Iowa |
Julissa Dionicio |
Jennifer Dionicio |
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 |
626 |
2023-03-16 11:18 |
Anonymous (not verified) |
94.188.207.224 |
Raymond Carpenter |
1655 230th St Tipton IA 52772 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-16 |
Raymond Carpenter |
badseedmudraching@gmail.com |
Tipton |
Cedar |
Iowa |
Mitzi Hoeger |
Roger Gibbs |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Raymond Carpenter |
badseedmudracing@gmail.com |
Self |
Tipton |
Cedar |
IA |
Roger Gibbs |
Mitzi Hoeger |
Signed |
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 |
577 |
2022-12-02 12:31 |
Anonymous (not verified) |
74.84.79.78 |
Juan A. Martinez-Salazar |
7085 Bloomfield Rd. 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. |
2022-01-02 |
Juan A. Martinez Salazar |
bananas94@icloud.com |
Des Moines |
Polk |
IA |
Racio Rodriguez |
Manuel Gonzalez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Juan A. Martinez- Salazar |
bananas94@icloud.com |
President |
Des Moines |
Polk |
IA |
Racio Rodriguez |
Manuel Gonzales |
Signed |
656 |
2023-04-19 10:46 |
Anonymous (not verified) |
94.188.205.174 |
Brad Anthony Logging LLC |
307 Commercial St, Strawberry Point IA 52076 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-18 |
Brad Anthony |
banthony6487@gmail.com |
Strawberry Point |
Clayton |
Iowa |
Roger Gibbs |
Mitzi Hoeger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Anthony |
banthony6487@gmail.com |
Self |
Strawberry Point |
Clayton |
Iowa |
Mitzi Hoeger |
Roger Gibbs |
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 |
312 |
2021-08-18 22:29 |
Anonymous (not verified) |
166.181.81.19 |
Basset Express Inc. |
1572 Underwood 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. |
2021-08-18 |
Jay R Chelf |
bassetexpress@yahoo.com |
Muscatine |
Muscatine |
IA |
Bill Petersen |
Jody L Young |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Patricia Ann Chelf |
bassetexpress@gmail.com |
President |
Muscatine |
Muscatine |
Iowa |
Bill Petersen |
Jody L Young |
Signed |
979 |
2024-05-10 14:40 |
Anonymous (not verified) |
94.188.207.224 |
Paradigm Group, LLC |
3263 Cumming Road, 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. |
2024-05-10 |
Hunter Brown |
bbpropertymaintenance1@gmail.com |
Ankeny |
Polk County |
Iowa |
Landon Brown |
Ryan Rose |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kelsey Prince |
office@prdgmgroup.com |
Office Manager |
Cumming |
Madison |
Iowa |
Kyle McGinn |
Robin McGinn |
Signed |
567 |
2022-11-14 18:21 |
Anonymous (not verified) |
166.181.83.71 |
Beasts Bussiness |
1305 N 6th St Apt. 6 Indianola, IA 50125 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-11-14 |
Jonathan Brice Robinson |
Beastsbeekeeping@gmail.com |
Indianola |
Warren |
Iowa |
Timothy Williams Robinson |
Josiah Grant Robinson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jonathan Brice Robinson |
Beastsbeekeeping@gmail.com |
Owner |
Indianola |
Warren |
Iowa |
Timothy Williams Robinson |
Josiah Grant Robinson |
Signed |
245 |
2021-04-22 10:54 |
Anonymous (not verified) |
172.83.18.1 |
Skyway Inc |
7030 27th Way, Clear Lake, IA 50428 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-22 |
Brad Thompson |
becky@fgains.com |
Clear Lake |
Cerro Gordo |
Iowa |
Debbie Otto |
Paxton Farmer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Thompson |
becky@fgains.com |
Owner |
Clear Lake |
Cerro Gordo |
Iowa |
Debbie Otto |
Paxton Farmer |
Signed |
246 |
2021-04-22 10:56 |
Anonymous (not verified) |
172.83.18.1 |
Skyway Inc |
7030 27th Way, Clear Lake, IA 50428 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-22 |
Mary Thompson |
becky@fgains.com |
Clear Lake |
Cerro Gordo |
Iowa |
Debbie Otto |
Paxton Farmer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Thompson |
becky@fgains.com |
Owner |
Clear Lake |
Cerro Gordo |
Iowa |
Debbie Otto |
Paxton Farmer |
Signed |
477 |
2022-05-19 11:49 |
Anonymous (not verified) |
172.86.13.54 |
BOLT HOLDINGS Inc. and Holt Precision dba Holt Bladeworks and Holt Kinetic Solutions |
3230 N. Center Point Rd Unit 204, Marion, IA 52302 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-19 |
Ben Congleton |
Ben@holtkineticsolutions.com |
Cedar Rapids |
Linn |
Iowa |
Lisa Gleason |
Angey Holt |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa Gleason |
Lisa@holtkineticsolutions.com |
General Manager |
Marion |
Linn |
Iowa |
Lisa Gleason |
Danielle Congleton |
Signed |
146 |
2020-12-22 08:48 |
Anonymous (not verified) |
207.155.115.120 |
Kafer Lawn Care |
206 frentress dr Farley, IA 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. |
2020-12-22 |
Benjamin Terry Hayes |
benhayes1800@gmail.com |
Epworth |
Dubuque |
IA |
Adam Kafer |
Jeffery Sisler |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Benjamin Terry Hayes |
benhayes1800@gmail.com |
Owner |
Epworth |
Dubuque |
IA |
Adam Kafer |
Jeffery Sisler |
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 |
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 |
649 |
2023-04-07 11:56 |
Anonymous (not verified) |
94.188.207.223 |
Wilcox Property Management Inc |
300 N. 3rd St, Carlisle, IA 50047 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-07 |
William Wilcox |
bill@advancedasi.com |
Carlisle |
Polk |
IA |
Gary J Meyers |
James R Simmons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William Wilcox |
bill@advancedasi.com |
Owner |
Carlisle |
Polk |
IA |
Gary J Meyers |
James R Simmons |
Signed |
756 |
2023-08-28 09:10 |
Anonymous (not verified) |
94.188.205.177 |
J.R. Stelzer Co. |
5850 Russell Dr Ste 1, 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. |
2023-07-01 |
William James Stelzer |
bill@jrstelzer.com |
Lincoln |
Nebraska |
United States |
Michael G Stelzer |
Marcia Brouillette |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William James Stelzer |
bill@jrstelzer.com |
Officer |
Lincoln |
Lancaster |
NE |
Michael G. Stelzer |
Marcia Brouillette |
Signed |
375 |
2021-12-23 12:23 |
Anonymous (not verified) |
66.230.245.47 |
W. R. Elliot & Associates, Ltd. |
3306 Brook Hollow Dr, Asbury, IA 52002 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-12-23 |
William R. Elliot |
bill@wreassoc.com |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L. Spalla |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William R. Elliot |
bill@wreassoc.com |
President |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L Spalla |
Signed |
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 |
518 |
2022-07-21 10:58 |
Anonymous (not verified) |
75.162.31.164 |
Bengard Roofing LLC |
1927 Wethersfield Dr, Norwalk, IA 50211 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-07-21 |
Brandon Bengard |
bj@bengardroofing.com |
Norwalk |
Warren |
IA |
Rebecca Bengard |
Juhl Bengard |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brandon Bengard |
bj@bengardroofing.com |
Owner |
Norwalk |
Warren |
IA |
Becky Bengard |
Juhl Bengard |
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 |
86 |
2020-06-03 17:56 |
Anonymous (not verified) |
75.162.69.231 |
Blackford Foundations Inc |
501 SW Franklin Dr, Ankeny, IA 50023 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-05-01 |
Denny Lee Blackford |
blackfordfoundations@gmail.com |
Ankeny |
Polk |
Iowa |
Saree Luce |
Ricky Eatwell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Denny Lee Blackford |
blackfordfoundations@gmail.com |
Secretary |
Ankeny |
Polk |
Iowa |
Saree Luce |
Ricky Eatwell |
Signed |
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 |
764 |
2023-09-10 19:18 |
Anonymous (not verified) |
94.188.205.177 |
Heartland Ultrasonography Group |
1015 Woodland Drive Carlisle, Iowa 50047 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-09-10 |
Bradley C Curtis |
blc735@msn.com |
Carlisle |
Warren |
Iowa |
Dane Joseph Wright |
Michael Lee Guffey |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradley C Curtis |
Heartlandusgroup@outlook.com |
Co-owner llc |
Carlisle |
Warren |
Iowa |
Dane Joseph Wright |
Michael Lee Guffey |
Signed |
385 |
2022-01-11 08:27 |
Anonymous (not verified) |
173.29.238.103 |
Brilliant All-Seasons Lighting Inc. |
10357 NW 42nd St., Polk City, IA 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-11 |
Bradley Harold Loney |
bloney@live.com |
Polk City |
Polk |
Iowa |
Linda Delin |
Amanda Warywoda |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Katrina Loney |
katrinaloney@outlook.com |
Vice President |
Polk City |
Polk |
Iowa |
Linda Delin |
Amanda Warywoda |
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 |
107 |
2020-08-04 13:42 |
Anonymous (not verified) |
97.64.131.90 |
BNR Construction INC |
210 4th St Orient, IA 50858 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-08-04 |
Bennie Shinn |
bnrconstllc@gmail.com |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bennie Shinn |
bnrconstllc@gmail.com |
President |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
112 |
2020-08-26 10:18 |
Anonymous (not verified) |
97.64.131.90 |
BNR Construction INC |
210 4th St Orient, IA 50858 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-15 |
Bennie Shinn |
bnrconstllc@gmail.com |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bennie Shinn |
bnrconstllc@gmail.com |
President |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
111 |
2020-08-25 14:37 |
Anonymous (not verified) |
204.155.61.217 |
BNR Construction INC |
210 4th St Orient,Ia 50858 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-15 |
Bennie Shinn |
bnrconstructllc@gmail.com |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bennie Shinn |
bnrconstructllc@gmail.com |
President |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
231 |
2021-04-11 12:19 |
Anonymous (not verified) |
174.243.115.140 |
Blaser Plumbing Inc |
28933 Sieverding Ridge Rd Bellevue IA 52031 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-11 |
Michael Blaser |
bpi1999@hotmail.com |
Bellevue |
IA |
United States |
Joyce Langmeier |
Sylvester Langmeier |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Blaser |
bpi1999@hotmail.com |
Owner |
Bellevue |
IA |
United States |
Joyce Langmeier |
Sylvester Langmeier |
Signed |
424 |
2022-03-11 15:36 |
Anonymous (not verified) |
69.63.16.2 |
BR Flynn Co Inc |
16756 Corey Daniel Ct, Dubuque, IA 52001 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-11 |
Bruce R Flynn |
br.flynn4@gmail.com |
Dubuque |
Dubuque |
Iowa |
Rick Meyer |
Dyan Kriener |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bruce R Flynn |
br.flynn4@gmail.com |
President |
Dubuque |
Dubuque |
IA |
Rick Meyer |
Dyan Kriener |
Signed |
91 |
2020-06-17 17:47 |
Anonymous (not verified) |
166.182.83.28 |
BJJ Painting Inc |
6940 Rolling Ridge CT SW Cedar Rapids IA 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-06-17 |
Bradley Johnson |
brad.johnson@fivestarpainting.com |
Cedar Rapids |
Linn |
Iowa |
Mike McClure |
Tony Gaiffe |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradley Johnson |
brad.johnson@fivestarpainting.com |
President |
Cedar Rapids |
Linn |
Iowa |
Mike McClure |
Tony Gaiffe |
Signed |
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 |
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 |
602 |
2023-02-16 16:10 |
Anonymous (not verified) |
94.188.207.228 |
Friday After Work LLC |
2526 Rainbow Drive, Cedar Falls, IA 50613 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-01 |
Brady John Huls |
brady.cve@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Tyler Reynolds |
Joshua Carder |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brent Dunlop |
fawconstruction.ia@gmail.com |
Owner |
Cedar Falls |
Black Hawk |
Iowa |
Tyler Reynolds |
Joshua Carder |
Signed |
604 |
2023-02-16 16:13 |
Anonymous (not verified) |
94.188.207.226 |
Transcend Mind Body Wellness and Floatation Clinic |
409 Washington Street, Cedar Falls, IA 50613 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-01 |
Brady Huls |
brady.huls@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Morgan Huls |
Ashlyn Henry |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Morgan Huls |
transcendcedarfalls@gmail.com |
Owner |
Cedar Falls |
Black Hawk |
Iowa |
Brady Huls |
Ashlyn Henry |
Signed |
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 |
85 |
2020-06-03 17:53 |
Anonymous (not verified) |
75.162.69.231 |
Blackford Foundations Inc |
501 SW Franklin Dr, Ankeny, IA 50023 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-05-01 |
Brenda Marie Blackford |
brendab@blackfordfoundations.com |
Ankeny |
Polk |
Iowa |
Saree Luce |
Ricky Eatwell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brenda Marie Blackford |
brendab@blackfordfoundations.com |
President |
Ankeny |
Polk |
Iowa |
Saree Luce |
Ricky Eatwell |
Signed |
587 |
2023-01-09 10:04 |
Anonymous (not verified) |
173.27.230.122 |
Hatfield Co Inc |
307 E 20th St Box 185 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-09 |
Brenda Hatfield |
brenmarie137.bh@gmail.com |
Lovilia |
IA |
United States |
Jerry Griffin |
Dave Chesnut |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Boyle and Henderson |
joycem@boyleandhenderson.com |
Accountant |
Oskaloosa |
Marion |
Iowa |
Jerry Griffin |
Dave Chesnut |
Signed |
296 |
2021-07-29 08:51 |
Anonymous (not verified) |
204.155.61.217 |
Blaine Management Inc |
660 NE Dellwood Dr Apt 17, Waukee, IA 5063 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-07-29 |
Brent Ott |
brent@hailmayday.com |
Prior Lake |
Scott |
MN |
Ashley Kraft |
DocuSign |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brent Ott |
Brent@hailmayday.com |
Owner |
Prior Lake |
Scott |
MN |
Ashley Kraft |
Docusign |
Signed |
417 |
2022-03-03 13:20 |
Anonymous (not verified) |
67.41.107.230 |
Trility Group Holdings, Inc. |
14001 University Ave, Suite 300, Clive, IA 50125 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-03 |
Brenton David Rothchild |
brenton@trility.io |
Indianola |
Warren |
IA |
Devin Boyer |
Kyle Woiwood |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brenton David Rothchild |
brenton@trility.io |
Treasurer |
Indianola |
Warren |
IA |
Devon Boyer |
Kyle Woiwood |
Signed |
614 |
2023-02-28 07:24 |
Anonymous (not verified) |
94.188.207.229 |
River City Transport, Inc |
131 West 10th st, 4th floor Dubuque, IA 52001 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-02-28 |
Brian Brewer |
brian@rivercitylogistics.net |
Sparks |
NV |
United States |
Matthew Gazzola |
Jacob Shireman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brian Brewer |
brian@rivercitylogistics.net |
Vice President |
Sparks |
NV |
United States |
Matthew Gazzola |
Jacob Shireman |
Signed |
625 |
2023-03-09 10:27 |
Anonymous (not verified) |
94.188.207.230 |
River City Transport, Inc |
201 Lezlie dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-09 |
Brian Brewer |
brian@rivercitylogistics.net |
Sparks |
Washoe |
Nevada |
Jacob Shireman |
Matthew Gazzola |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brian Brewer |
brian@rivercitylogistics.net |
Vice President |
Sparks |
Washoe |
Nevada |
Jacob Shireman |
Matthew Gazzola |
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 |
419 |
2022-03-03 14:37 |
Anonymous (not verified) |
68.13.47.145 |
Trility Group Holdings, Inc |
14001 University Ave, Suite 300 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-03 |
James Brody Deren |
brody@trility.io |
Omaha |
Douglas |
Nebraska |
Devin Boyer |
Kyle Woiwood |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Brody Deren |
brody@trility.io |
Secretary |
Omaha |
Douglas |
Nebraska |
Devin Boyer |
Kyle Woiwood |
Signed |
319 |
2021-08-24 10:19 |
Anonymous (not verified) |
174.243.114.142 |
Sabbatical Services LLC |
20732 Johnson St., Milo, IA 50166 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-24 |
Bryce Gilbert |
bryce.ssllc@outlook.com |
Milo |
Warren |
Iowa |
Kathryn Gilbert |
Kolton Gilbert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bryce Gilbert |
bryce.ssllc@outlook.com |
President |
Milo |
Warren |
Iowa |
Kathryn Gilbert |
Kolton Gilbert |
Signed |
470 |
2022-05-12 14:28 |
Anonymous (not verified) |
173.184.134.123 |
Bryce Hoffert LLC |
1802 Lake Street Emmetsburg Iowa 50536 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-12 |
Bryce C Hoffert |
brycehoffertllc@gmail.com |
Emmetsburg |
Pala Alto |
Iowa |
Ray Hoffert |
Shelbie Hurdle |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bryce Hoffert |
brycehoffertllc@gmail.com |
member |
Emmetsburg |
Palo Alto |
Iowa |
Ray Hoffert |
Shelbie Hurdle |
Signed |
562 |
2022-11-04 10:32 |
Anonymous (not verified) |
98.159.123.124 |
Alli-Center |
555 Cameron Way Unit 2 North Liberty Iowa 52317 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-11-04 |
Bonnie Seely |
bseely4@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Jonah C Seely |
Hannah Seely |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bonnie Seely |
bseely4@gmail.com |
Owner/Self |
Cedar Rapids |
Linn |
Iowa |
Jonah Seely |
Hannah Seely |
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 |
172 |
2021-01-26 19:02 |
Anonymous (not verified) |
173.17.8.56 |
Hutch's Parking Lot Sweeping |
5235 JENNIFER 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. |
2021-01-26 |
Bill HUTCHINSON |
btnwhutch@aol.com |
PLEASANT HILL |
Iowa |
United States |
TRACY HUTCHINSON |
WHITNIE HUTCHINSON |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bill HUTCHINSON |
btnwhutch@aol.com |
Self |
PLEASANT HILL |
Iowa |
United States |
TRACY HUTCHINSON |
WHITNIE HUTCHINSON |
Signed |
337 |
2021-09-16 21:28 |
Anonymous (not verified) |
173.17.8.56 |
Hutch's Parking Lot Sweeping Inc. |
5235 Jennifer 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. |
2021-09-16 |
Bill E Hutchinson |
btnwhutch@aol.com |
Pleasant Hill |
Iowa |
Iowa |
Tracy Hutchinson |
Nic Hutchinson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bill E Hutchinson |
btnwhutch@aol.com |
Same |
Pleasant Hill |
Iowa |
Iowa |
Tracy Hutchinson |
Nic Hutchinson |
Signed |
394 |
2022-01-27 12:29 |
Anonymous (not verified) |
72.255.65.83 |
Rodgers’ Building & Remodeling Inc |
1003 NW 37th Street |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-28 |
Benjamin Rodgers |
btrdsm18@gmail.com |
Ankeny |
Polk |
Iowa |
Mary Rodgers |
Larry Joel |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mary Rodgers |
steff.m2096@yahoo.com |
President |
Ankeny |
Polk |
Iowa |
Ben Rodgers |
Larry Joel |
Signed |
160 |
2021-01-13 10:52 |
Anonymous (not verified) |
173.190.64.239 |
united workers inc |
711 4th st ne |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-13 |
mayra sapolvada |
buck@trvnet.net |
Belmond |
wright |
iowa |
shannon muhlenbruch |
Martha Leal |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
mayra sapulvada |
buck@trvnet.net |
president |
belmond |
wright |
ia |
shannon myhlenbruch |
martha leal |
Signed |
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 |
135 |
2020-11-20 11:05 |
Anonymous (not verified) |
208.95.1.97 |
Burds Communities Inc. |
606 S 3rd Street, Bellevue, IA 52031 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-11-20 |
Todd Burds |
burdshousing@yahoo.com |
Peosta |
Dubuque |
IA |
Paula Fitzgerald |
Jena Wilwert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Todd Burds |
burdshousing@yahoo.com |
President |
Peosta |
Dubuque |
IA |
Paula Fitzgerald |
Jena Wilwert |
Signed |
136 |
2020-11-20 11:06 |
Anonymous (not verified) |
208.95.1.97 |
Burds Communities Inc. |
606 S 3rd Street, Bellevue, IA 52031 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-11-20 |
Tim Burds |
burdshousing@yahoo.com |
Peosta |
Dubuque |
IA |
Paula Fitzgerald |
Jena Wilwert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tim Burds |
burdshousing@yahoo.com |
Vice President |
Peosta |
Dubuque |
IA |
Paula Fitzgerald |
Jena Wilwert |
Signed |
372 |
2021-12-09 14:17 |
Anonymous (not verified) |
204.155.61.217 |
Buena Vista Auto Sales Inc |
1030 Lake Ave, Storm Lake, IA 50588 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-12-09 |
Arturo Lozano |
bvusedcars@siouxland.com |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Michelle Munoz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Arturo Lozano |
bvusedcars@siouxland.com |
Owner |
storm Lake |
Buena Vista |
IA |
Jared Brashears |
Michelle Munoz |
Signed |
116 |
2020-09-11 11:42 |
Anonymous (not verified) |
69.57.22.68 |
Brush and Weed Control Specialists, Inc. |
1108 230th Street - Algona, IA 50511 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-09-11 |
Ruth Jean Lindgren |
bwcontrol@netamumail.com |
Algona |
Kossuth |
Iowa |
James Black |
Katie Melvin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Donald H Reffer |
bwcontrol@netamumail.com |
President and General Manager |
Algona |
Kossuth |
Iowa |
James Black |
Katie Melvin |
Signed |
703 |
2023-06-27 07:05 |
Anonymous (not verified) |
94.188.207.229 |
Dancom Inc |
1001 Office Park Rd, West Des Moines, IA 50265 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-26 |
Calvin Otundo |
calvin@dancoms.com |
Waukee |
Polk |
IA |
Joe Meyers |
Robert Simmons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Calvin Otundo |
calvin@dancoms.com |
Owner |
Waukee |
Polk |
IA |
Robert Simmons |
Joe Meyers |
Signed |
288 |
2021-07-22 16:17 |
Anonymous (not verified) |
104.166.243.230 |
Renewal By Anderson |
517 railroad ave. West Des Moines |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-07-22 |
Cameron Thede |
camthede22@gmail.com |
Windsor Heights |
Polk |
Iowa |
Mac Laven |
sdofkn |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Renewal By Andersen |
james@rbadesmoines.com |
Subcontractor |
West Des Moines |
Polk |
IA |
Mac Laven |
lsdfkn lsadnf |
Signed |
606 |
2023-02-20 20:55 |
Anonymous (not verified) |
94.188.205.168 |
Carlos Ortiz LLC |
4335 NE 23rd Ave Des Moines, IA 50317 Estados Unidos |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-02-20 |
Carlos Ortiz |
carlosoframing@gmail.com |
Des Moines |
Polk |
Iowa |
Luz picazo |
Brando ortiz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Carlos Ortiz |
carlosograming@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Luz picazo |
Brando Ortiz |
Signed |
479 |
2022-05-26 14:05 |
Anonymous (not verified) |
71.28.218.225 |
TRAER MUSEUM |
514 2ND ST. TRAER, IA 50675 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-26 |
Carol Boyce |
carolwoodboyce@gmail.com |
Dysart |
Tama |
IOWA |
EDWARD HOEG |
KIM DAHMS |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CAROL BOYCE |
carolwoodboyce@gmail.com |
VICE PRESIDENT |
Dysart |
Tama |
IOWA |
ED HOEG |
KIM DAHMS |
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 |
590 |
2023-01-18 15:14 |
Anonymous (not verified) |
172.86.13.54 |
BOLT HOLDINGS, Inc and Holt Precision dba Holt Bladeworks and Holt Kinetic Solutions |
3230 N Center Point Rd |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-18 |
Carter Kramer |
Carter@Holtkineticsolutions.com |
Cedar Rapids |
Linn |
Iowa |
Lisa Gleason |
Tricia Kummer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa Gleason |
Lisa@Holtkineticsolutions.com |
General Manager |
Marion |
Linn |
Iowa |
Tricia Kummer |
Marla McFall |
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 |
230 |
2021-04-06 21:15 |
Anonymous (not verified) |
173.23.145.187 |
Jose J Framing |
5301 SE 24th St. 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. |
(2) I decline to reject the employer’s liability coverage. |
2021-01-01 |
Jose J. Castillo |
castillojosejonathan7@gmail.com |
Des Moines |
Polk |
United States |
Perla Landaverde Garcia |
Alma Y. Gaytan |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Jose J. Castillo |
castillojosejonathan7@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Perla Landaverde Garcia |
Alma Y. Gaytan |
Signed |
441 |
2022-04-11 13:15 |
Anonymous (not verified) |
75.162.175.12 |
Castro construction LLC |
1712 carpenter av desmoines 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. |
2022-04-11 |
Carlos Alberto castro Alcántara |
castrodvxhd@gmail.com |
Estados Unidos |
Iowa |
Desmoines |
Blanca Yadira montes Quiñones |
Maynor Noe padilla bonilla |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Carlos Alberto castro Alcántara |
castrodvxhd@gmail.com |
Owner |
Estados unidos |
Iowa |
Desmoines |
Blanca Yadira montes Quiñones |
Maynor Noe Padilla Bonilla |
Signed |
442 |
2022-04-11 13:15 |
Anonymous (not verified) |
75.162.175.12 |
Castro construction LLC |
1712 carpenter av desmoines 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. |
2022-04-11 |
Carlos Alberto castro Alcántara |
castrodvxhd@gmail.com |
Estados Unidos |
Iowa |
Desmoines |
Blanca Yadira montes Quiñones |
Maynor Noe padilla bonilla |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Carlos Alberto castro Alcántara |
castrodvxhd@gmail.com |
Owner |
Estados unidos |
Iowa |
Desmoines |
Blanca Yadira montes Quiñones |
Maynor Noe Padilla Bonilla |
Signed |
443 |
2022-04-11 13:15 |
Anonymous (not verified) |
75.162.175.12 |
Castro construction LLC |
1712 carpenter av desmoines 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. |
2022-04-11 |
Carlos Alberto castro Alcántara |
castrodvxhd@gmail.com |
Estados Unidos |
Iowa |
Desmoines |
Blanca Yadira montes Quiñones |
Maynor Noe padilla bonilla |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Carlos Alberto castro Alcántara |
castrodvxhd@gmail.com |
Owner |
Estados unidos |
Iowa |
Desmoines |
Blanca Yadira montes Quiñones |
Maynor Noe Padilla Bonilla |
Signed |
685 |
2023-06-15 12:30 |
Anonymous (not verified) |
94.188.205.168 |
Des Moines Marble & Mantel Co. Inc. |
1507 Ohio Street 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. |
2023-06-15 |
Benjamin Campos Rojas |
caya05rojas@gmail.com |
Des Moines |
Polk county |
Iowa |
Erica Antonio Maya |
Ana Antonio Maya |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mario DeMarco |
sandyatdmmarble@aol.com |
Owner |
Des Moines |
Polk County |
Iowa |
Erica Antonio Maya |
Ana Antonio Maya |
Signed |
687 |
2023-06-16 07:59 |
Anonymous (not verified) |
94.188.207.230 |
Benjamin Campos Rojas |
4024 52nd Street 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. |
2023-06-16 |
Benjamin Campos Rojas |
caya05rojas@gmail.com |
Des Moines |
Polk |
Iowa |
Erica Antonio Maya |
Ana Antonio Maya |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Benjamin Campos Rojas |
caya05rojas@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Erica Antonio Maya |
Ana Antonio Maya |
Signed |
444 |
2022-04-14 15:50 |
Anonymous (not verified) |
72.10.21.42 |
Babcock Services Idaho, Inc. |
8113 W QUINAULT AVENUE 201, Kennewick, WA 99336 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-04-14 |
Carmen Clyde |
CCLYDE@BABCOCKSERVICES.COM |
KENNEWICK |
WA |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CARMEN CLYDE |
CCLYDE@BABCOCKSERVICES.COM |
Secretary |
KENNEWICK |
Benton |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
445 |
2022-04-14 15:52 |
Anonymous (not verified) |
72.10.21.42 |
Babcock Services Idaho, Inc. |
8113 W QUINAULT AVENUE 201, Kennewick, WA 99336 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-04-14 |
Keith Myers |
CCLYDE@BABCOCKSERVICES.COM |
KENNEWICK |
Benton |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CARMEN CLYDE |
CCLYDE@BABCOCKSERVICES.COM |
Secretary |
KENNEWICK |
Benton |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
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 |
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 |
471 |
2022-05-13 10:08 |
Anonymous (not verified) |
104.166.245.37 |
Juan Ramiro Rivas Perez |
6211 SW 5th Street. 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. |
2022-05-02 |
Juan Ramiro Rivas Perez |
cecyperezv1982@icloud.com |
Des Moines |
Polk |
Iowa |
Carmen Perez |
Oscar Ramirez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Juan Ramiro Rivas Perez |
cecyperezv1982@icloud.com |
Secretary |
Des Moines |
Polk |
Iowa |
Carmen Perez |
Oscar Ramirez |
Signed |
358 |
2021-11-15 09:39 |
Anonymous (not verified) |
165.225.57.41 |
Jerry Steward Trucking Inc. |
319 W. 7th Street, Janesville, IA 50647 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-22 |
Jerry Steward Sr. |
cedarfalls.oil@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jerry Steward Jr. |
cedarfalls.oil@gmail.com |
Vice-President |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
359 |
2021-11-15 09:43 |
Anonymous (not verified) |
165.225.57.41 |
Jerry Steward Trucking Inc |
319 W. 7th Street, Janesville, IA 50647 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-22 |
Jerry Steward Jr. |
cedarfalls.oil@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jerry Steward Sr. |
cedarfalls.oil@gmail.com |
President |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
360 |
2021-11-15 09:47 |
Anonymous (not verified) |
165.225.57.41 |
Jerry Steward Trucking Inc |
319 W. 7th Street, Janesville, IA 50647 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-22 |
Ruth Steward |
cedarfalls.oil@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jerry Steward Sr. |
cedarfalls.oil@gmail.com |
President |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
565 |
2022-11-14 08:22 |
Anonymous (not verified) |
97.119.175.158 |
CenterLine Electric Inc |
22004 185th St Council Bluffs 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. |
2022-11-14 |
Jonathon w Haldeman |
centerline.electric@yahoo.com |
council bluffs |
pottawattamie |
Iowa |
cathy haldeman |
koleen haldeman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
jonathon haldeman |
centerline.electric@yahoo.com |
owner |
council bluffs |
pottawattamie |
iowa |
cathy haldeman |
koleen haldeman |
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 |
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 |
18 |
2019-12-16 14:00 |
Anonymous (not verified) |
206.80.132.15 |
Cresco Family Dentistry P.C. |
210 N Elm St Cresco, IA 52136 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-12-16 |
Jeffrey K Haw |
cfdentistry@iowatelecom.net |
Cresco |
Howard |
Iowa |
Don Dietzenbach |
Kim Holmes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffrey K Haw |
cfdentistry@iowatelecom.net |
President |
Cresco |
Howard |
Iowa |
Don Dietzenbach |
Kim Holmes |
Signed |
19 |
2019-12-16 14:04 |
Anonymous (not verified) |
206.80.132.15 |
Cresco Family Dentistry P.C. |
210 N Elm St Cresco, IA 52136 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-12-16 |
Shirlee J Haw |
cfdentistry@iowatelecom.net |
Cresco |
Howard |
Iowa |
Don Dietzenbach |
Kim Holmes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffrey K Haw |
cfdentistry@iowatelecom.net |
President |
Cresco |
Howard |
Iowa |
Don Dietzenbach |
Kim Holmes |
Signed |
709 |
2023-07-17 15:46 |
Anonymous (not verified) |
94.188.205.166 |
Breuer Roofing Company |
3021 Sunburst Dr. Bettendorf, IA 52722 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-07-17 |
Chad Breuer |
chadbreuer@gmail.com |
Bettendorf |
Scott |
IA |
Caroline Kristina Breuer |
Patricia Ann Breuer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chad Michael Breuer |
chadbreuer@gmail.com |
President |
Bettendorf |
Scott |
IA |
Caroline Kristina Breuer |
Patricia Ann Breuer |
Signed |
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 |
747 |
2023-08-19 15:30 |
Anonymous (not verified) |
94.188.207.229 |
Arneson Tree Service |
901 s Washington st Lake Mills IOWA 50450 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-19 |
Charles Douglas Arneson |
charles.arneson@aol.com |
Lake Mills |
Winnebago |
IOWA |
Amber Arneson |
Carter Arneson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Charles Douglas Arneson |
charles.arneson@aol.com |
Owner |
Lake Mills |
Winnebago |
IOWA |
Amber arneson |
Carter Arneson |
Signed |
332 |
2021-09-13 13:30 |
Anonymous (not verified) |
173.23.250.91 |
Cheri’s roofing |
230 palomino pkwy 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. |
(2) I decline to reject the employer’s liability coverage. |
2021-09-13 |
Cheryl Martinez |
cheri6876@yahoo.com |
Des Moines |
Polk |
Iowa |
Cheryl Martinez |
Cheryl martinez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chery Martinez |
cheri6876@yahoo.com |
Owner |
Des Moines |
Polk |
Iowa |
Cheryl Martinez |
Cheryl Martinez |
Signed |
588 |
2023-01-13 10:49 |
Anonymous (not verified) |
173.17.248.155 |
Cheri's Roofing |
1842 Glenwood Circle 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. |
2023-01-13 |
Cheryl Martinez |
cheri6876@yahoo.com |
Des Moines |
Polk |
Iowa |
Jessica L Newton |
Thomas C Newton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cheryl Martinez |
cheri6876@yahoo.com |
Owner |
Des Moines |
Polk |
Iowa |
Jessica L Newton |
Thomas C Newton |
Signed |
24 |
2020-01-02 09:12 |
Anonymous (not verified) |
207.191.194.182 |
Waukee CabinetWorks LLC |
70 SE Laurel St, Waukee IA 50263 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-12-23 |
Amy Balm |
chris.rappe@waukeecabinetworks.com |
Waukee |
Dallas |
Iowa |
Chris Andrews |
Dave Creighton Sr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chris Rappe |
chris.rappe@waukeecabinetworks.com |
Operations Manager |
Waukee |
Dallas |
IA |
Chris Andrews |
Dave Creighton SR |
Signed |
25 |
2020-01-02 09:17 |
Anonymous (not verified) |
207.191.194.182 |
Waukee CabinetWorks LLC |
70 SE Laurel St, Waukee IA 50263 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-12-23 |
Jason Balm |
chris.rappe@waukeecabinetworks.com |
Waukee |
Dallas |
Iowa |
Chris Andrews |
Dave Creighton Sr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chris Rappe |
chris.rappe@waukeecabinetworks.com |
Operations Manager |
Waukee |
Dallas |
Iowa |
Chris Andrews |
Dave Creighton SR |
Signed |
615 |
2023-02-28 08:15 |
Anonymous (not verified) |
94.188.207.224 |
River City Transport |
201 Lezlie Dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2023-02-28 |
Christopher Ryan Brewer |
chris@rivercitylogistics.net |
Peosta |
Dubuque County |
Iowa |
Brian Brewer |
Nicholas Lester |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chris Brewer |
chris@rivercitylogistics.net |
Owner |
Peosta |
Iowa |
United States |
Brian Brewer |
Nicholas Lester |
Signed |
378 |
2022-01-03 15:16 |
Anonymous (not verified) |
217.180.230.157 |
True360, Inc. |
1805 Collaboration Place, Suite 1300, Ames, Iowa 50010 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-03 |
Christopher James |
chris@true-360.com |
Ames |
Iowa |
United States |
Jesse Kisker |
Cody Kapka |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christopher James |
chris@true-360.com |
President and Chief Executive Officer |
Ames |
Iowa |
United States |
Jesse Kisker |
Cody Kapka |
Signed |
473 |
2022-05-16 14:20 |
Anonymous (not verified) |
167.142.231.34 |
Trust Builders, LLC |
1055 Jordan Creek Parkway, Suite 200, West Des Moines, IA 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-16 |
Christopher Dean Petersen |
chrispetersen@trustbuildersiowa.com |
Polk City |
Polk |
Iowa |
Curtis William Blake |
Joseph Duane Meints |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christopher Dean Petersen |
chrispetersen@trustbuildersiowa.com |
Owner |
Polk City |
Polk |
Iowa |
Curtis William Blake |
Joseph Duane Meints |
Signed |
599 |
2023-02-13 12:14 |
Anonymous (not verified) |
94.188.207.227 |
Christian Gilbert |
3174 HWY F48 W. Newton, IA 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. |
2023-02-13 |
Christian Gilbert |
christian.gilbert14@gmail.com |
Newton |
Jasper |
Iowa |
Marcus Thompson |
Crystal Ward |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christian Gilbert |
christian.gilbert14@gmail.com |
self |
Newton |
Jasper |
Iowa |
Marcus Thompson |
Crystal Ward |
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 |
137 |
2020-11-23 10:11 |
Anonymous (not verified) |
207.32.14.70 |
Community Ambulance Service, Inc. |
15 N 1st St., Estherville, IA 51334 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-11-18 |
Christopher Fuhrman |
christopher.furhrman@edwardjones.com |
Spirit Lake |
Dickinson |
Iowa |
Sara M Fisher |
Abbie J Fuhrman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christopher Fuhrman |
christopher.fuhrman@edwardjones.com |
President |
Spirit Lake |
Dickinson |
Iowa |
Sara M Fisher |
Abbie J Fuhrman |
Signed |
147 |
2020-12-29 13:57 |
Anonymous (not verified) |
208.38.231.99 |
CJ Construction |
2129N Zenith Ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-29 |
Christine Ekin John Ekin |
chrohn2009@yahoo.com |
Davenport |
Iowa |
United States |
Christine Ekin |
John J Ekin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CJ Construction |
chrohn2009@yahoo.com |
Co Owner |
Davenport |
Iowa |
United States |
Christine Ekin |
John J Ekin |
Signed |
301 |
2021-08-04 10:05 |
Anonymous (not verified) |
63.142.48.170 |
Vision Homes Inc |
2566 Ivanhoe 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. |
2021-07-02 |
DeeAnn Nejdl |
chucknejdl@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Melanie Heitman |
Dan Lillis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
DeeAnn Nejdl |
chucknejdl@gmail.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Melanie Heitman |
Dan Lillis |
Signed |
302 |
2021-08-04 10:08 |
Anonymous (not verified) |
63.142.48.170 |
Vision Homes Inc |
2566 Ivanhoe 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. |
2021-07-02 |
Charles Nejdl |
chucknejdl@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Melanie Heitman |
Dan Lillis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Charles Nejdl |
chucknejdl@gmail.com |
Vice President |
Cedar Rapids |
Linn |
Iowa |
Melanie Heitman |
Dan Lillis |
Signed |
290 |
2021-07-26 12:29 |
Anonymous (not verified) |
208.95.1.97 |
Chyma's Welding, Inc. |
206 2nd Ave, Toledo IA 52342 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-08-01 |
Chad Chyma |
Chymamenwelding@windstream.net |
Toledo |
Tama |
IA |
Matt Zmolek |
Michaela Chyma |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chad |
Chymamenwelding@windstream.net |
Director |
Toledo |
IA |
United States |
Matt Zmolek |
Michaela Chyma |
Signed |
291 |
2021-07-26 12:31 |
Anonymous (not verified) |
208.95.1.97 |
Chyma's Welding, Inc. |
206 2nd Ave, Toledo IA 52342 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-01 |
Chad Chyma |
Chymamenwelding@windstream.net |
Toledo |
Tama |
Iowa |
Matt Zmolek |
Michaela Chyma |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chad Chyma |
Chymamenwelding@windstream.net |
Director |
Toledo |
Tama |
Iowa |
Matt Zmolek |
Michaela Chyma |
Signed |
292 |
2021-07-26 12:38 |
Anonymous (not verified) |
208.95.1.97 |
Chyma's Machine and Welding Shop, Inc. |
206 2nd Ave, Toledo IA 52342 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-08-01 |
Chad Chyma |
Chymamenwelding@windstream.net |
Toledo |
Tama |
Iowa |
Matt Zmolek |
Michaela Chyma |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chad Chyma |
Chymamenwelding@windstream.net |
Director |
Toledo |
Tama |
Iowa |
Matt Zmolek |
Michaela Chyma |
Signed |
293 |
2021-07-26 12:39 |
Anonymous (not verified) |
208.95.1.97 |
Chyma's Machine and Welding Shop, Inc. |
206 2nd Ave, Toledo IA 52342 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-01 |
Chad Chyma |
Chymamenwelding@windstream.net |
Toledo |
Tama |
Iowa |
Matt Zmolek |
Michaela Chyma |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chad Chyma |
Chymamenwelding@windstream.net |
Director |
Toledo |
Tama |
IA |
Matt Zmolek |
Michaela Chyma |
Signed |
363 |
2021-11-17 09:33 |
Anonymous (not verified) |
64.5.67.201 |
OC Deliver Inc |
207 Central Avenue NE, Orange City, IA 51041 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-25 |
Joe Clarey |
ciui@orangecitycomm.net |
LeMars |
Plymouth |
Iowa |
Daryl Beltman |
Lori Mars |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joe Clarey |
ciui@orangecitycomm.net |
President |
LeMars |
Plymouth |
Iowa |
Daryl Beltman |
Lori Mars |
Signed |
364 |
2021-11-17 09:36 |
Anonymous (not verified) |
64.5.67.201 |
OC Deliver Inc |
207 Central Avenue NE, Orange City, IA 51041 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-25 |
Josh Van Es |
ciui@orangecitycomm.net |
Orange City |
Sioux |
Iowa |
Daryl Beltman |
Lori Mars |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Josh Van Es |
ciui@orangecitycomm.net |
Secretary/Treasurer |
Orange City |
Sioux |
Iowa |
Daryl Beltman |
Lori Mars |
Signed |
365 |
2021-11-18 11:48 |
Anonymous (not verified) |
64.5.67.201 |
C & H Body Repair Inc. |
707 Lincoln Ave SE, Orange City, IA 51041 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-11-12 |
Aaron Huizenga |
ciui@orangecitycomm.net |
Orange City |
Sioux |
Iowa |
Daryl Beltman |
Lori Mars |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Aaron Huizenga |
ciui@orangecitycomm.net |
President |
Orange City |
Sioux |
Iowa |
Daryl Beltman |
Lori Mars |
Signed |
90 |
2020-06-10 11:46 |
Anonymous (not verified) |
173.28.7.32 |
DMG INSTALLATIONS INC |
5534 NE 17TH ST #4 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-06-10 |
CLIFFORD LEE BAKER |
CLBAKER@MEDIACOMBB.NET |
ALTOONA |
POLK |
IOWA |
DAVID PAUL DUNLAP |
JASON DAVID MUSSO |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CLIFFORD LEE BAKER |
CLBAKER@MEDIACOMBB.NET |
PRESIDENT |
ALTOONA |
POLK |
IOWA |
JASON DAVID MUSSO |
DAVID PAUL DUNLAP |
Signed |
469 |
2022-05-12 11:38 |
Anonymous (not verified) |
173.23.25.243 |
RS- Remodelers |
2863 104th St Urbandale IA 50322 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2022-05-12 |
Stephen Dillon |
clearchoicedesmoinesia@gmail.com |
Waukee |
Dallas |
IA |
Rob Nevitt |
Jordan Nevitt |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Stephen |
clearchoicedesmoinesia@gmail.com |
Owner |
Waukee |
Dallas |
IA |
Rob Nevitt |
Jordan Nevitt |
Signed |
642 |
2023-03-30 09:56 |
Anonymous (not verified) |
94.188.205.174 |
Adamantine Spine Moving |
2726 Independence Road 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. |
2023-03-30 |
John Clifford Wallace |
cliff.wallace@spinemoving.com |
Des Moines |
Polk |
IA |
Taylor Christian Roth |
Ashley Anne Koch |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ashley Anne Koch |
ashley.koch@spinemoving.com |
HR, Safety and Compliance Manager |
Des Moines |
Polk |
Iowa |
Taylor Christian Roth |
John Clifford Wallace |
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 |
726 |
2023-08-02 17:30 |
Anonymous (not verified) |
94.188.205.169 |
Furever Friends of Appanoose, Inc |
19507 Hwy 2, Centerville, Iowa 52544 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-02 |
Clint Raymond Housh |
clinthoush@lockridgeinc.com |
Centerville |
Appanoose |
Iowa |
Brian Seeman |
Drew Power |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Clint Housh |
clinthoush@lockridgeinc.com |
Vice President |
Centerville |
Appanoose |
Iowa |
Brian Seeman |
Drew Power |
Signed |
101 |
2020-07-16 13:07 |
Anonymous (not verified) |
173.28.28.57 |
Weikert Properties, LLC |
34520 175th Street, Cedar Falls IA 5061 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-06-23 |
Caleb Weikert |
cmins_re@mchsi.com |
Cedar Falls |
Grundy |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Caleb Weikert |
cmins_re@mchsi.com |
Self |
Cedar Falls |
Grundy |
Iowa |
Chad Campbell |
Roxanne Kolder |
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 |
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 |
43 |
2020-02-28 09:50 |
Anonymous (not verified) |
173.24.140.77 |
W R Main Contractor Inc |
1620 NW 78th Street, Clive, IA 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-28 |
Cindy Jo Ohmart |
co4mainco@aol.com |
West Des Moines |
Polk |
Iowa |
Jill Ann Reber |
Alane Marguerite Richardson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mark I Main |
markmain@icloud.com |
President |
Waukee |
Dallas |
Iowa |
Jill Ann Reber |
Alane Marguerite Richardson |
Signed |
126 |
2020-10-28 14:31 |
Anonymous (not verified) |
104.207.25.44 |
Little Bison Daycare Center |
404 2nd St. NW Buffalo Center, IA 50424 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-10-28 |
Cody Tyler Wirtjes |
cody@afschem.com |
Buffalo Center |
Winnebago |
Iowa |
Michael James Perkins |
Garrett Alan Asmus |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cody Tyler Wirtjes |
cody@afschem.com |
Board President |
Buffalo Center |
Winnebago |
Iowa |
Michael James Perkins |
Garrett Alan Asmus |
Signed |
435 |
2022-03-28 07:14 |
Anonymous (not verified) |
75.162.66.125 |
Jenkins Electric LLC |
304 E North St. Prairie 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. |
2022-03-28 |
Colten Jenkins |
colten@jenkins-electric.com |
Prairie City |
Jasper |
Iowa |
Kristin Jenkins |
David Jennings |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Colten Jenkins |
colten@jenkins-electric.com |
Owner |
Prairie City |
Jasper |
Iowa |
Kristin Jenkins |
David Jennings |
Signed |
428 |
2022-03-23 12:00 |
Anonymous (not verified) |
76.76.231.229 |
Connelly Sanitation Inc |
108 S. 14th St. Fairfield IA 52556 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-23 |
Richard Raymond Vogt |
connelly.inc@outlook.com |
Fairfield |
Jefferson |
Iowa |
Mindy Lynn Vogt |
Chester James Vogt |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Richard Raymond Vogt |
connelly.inc@outlook.com |
Self |
Fairfield |
Jefferson |
Iowa |
Mindy Lynn Vogt |
Chester James Vogt |
Signed |
760 |
2023-09-01 08:43 |
Anonymous (not verified) |
94.188.207.226 |
Paradigm Group, LLC |
3263 Cumming Road, 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. |
2023-09-01 |
Conor Davis |
conor@cdavisflooring.com |
Urbandale |
Dallas |
Iowa |
Jered Holker |
Wes Duncan |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ryan Shabino |
ryan@prdgmgroup.com |
Owner |
Cumming |
Madison |
Iowa |
Wes Duncan |
Jered Holker |
Signed |
593 |
2023-01-30 10:39 |
Anonymous (not verified) |
69.18.9.193 |
ABC Fire Extinguisher Sales & Service, Inc. |
112 Broadway Street Suite 2, West Burlington, IA 52655 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or 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 |
Derek Stotlar |
contactabc@abc-fire.com |
Sperry |
Des Moines |
IA |
Kori Stotlar |
Jeff Elliott |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kori Stotlar |
kstotlar@abc-fire.com |
President |
Sperry |
Des Moines |
IA |
Jeff Elliott |
Kim Eland |
Signed |
232 |
2021-04-12 11:14 |
Anonymous (not verified) |
74.84.91.178 |
Heim Enterprises LLC |
13532 Mueller Parkway, Sherrill, IA 52073 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-01 |
Cory Heim |
corypheim@gmail.com |
Sherrill |
Dubuque |
Iowa |
Gabe Drewelow |
Brenda Lewis |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Cory Heim |
corypheim@gmail.com |
owner |
Sherrill |
Dubuque |
Iowa |
Gabe Drewelow |
Brenda Lewis |
Signed |
723 |
2023-08-01 15:37 |
Anonymous (not verified) |
94.188.205.169 |
Flow Media, Inc |
1710 Wenig Rd NE |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-01 |
Courtney Tabelisma Ball |
courtney@flowmedia.com |
Cedar Rapids |
IA |
United States |
Hannah Jane White |
Gregory Michael White |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Courtney Tabelisma Ball |
courtney@flowmedia.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Sonya Catherine Geenen |
Gregory Michael White |
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 |
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 |
58 |
2020-04-14 08:32 |
Anonymous (not verified) |
174.217.17.57 |
Society of St Vincent de Paul, District Counsel Waterloo Iowa |
320 Broadway St PO Box 2727 Waterloo IA 50704 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-14 |
Rodney Crowe |
crorod@aol.com |
Waterloo |
Blackhawk |
Iowa |
George W Karnivk |
Glynis R Worthington |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph D Sobczyk |
joczyk@aol.com |
Corporate Treasurer |
Cdear Falls |
Blackhawk |
Iowa |
George W Karnick |
Glynis R Worthington |
Signed |
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 |
754 |
2023-08-21 17:14 |
Anonymous (not verified) |
94.188.205.177 |
Burgess Investments DBA Heartland Pest Control Inc |
PO Box 8043 Cedar Rapids, IA 52408 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-21 |
CURT BURGESS |
curtburgess73@gmail.com |
CEDAR RAPIDS |
IA |
United States |
Doug Wilson |
Michael McMeins |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CURT BURGESS |
curtburgess73@gmail.com |
Self |
CEDAR RAPIDS |
IA |
United States |
Doug Wilson |
Michael McMeins |
Signed |
39 |
2020-02-10 16:37 |
Anonymous (not verified) |
67.212.103.193 |
Voelker Property Management, LLC |
1705 Quail Run Lane, Cedar Falls, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-10 |
Craig D Voelker |
cvoelker@cfu.net |
Cedar Falls |
Black Hawk |
Iowa |
Craig DVoelker |
Nikki D Voelker |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Craig D Voelker |
cvoelker@cfu.net |
Owner |
Cedar Falls |
Black Hawk |
Iowa |
Craig D Voelker |
Nikki D Voelker |
Signed |
737 |
2023-08-10 21:39 |
Anonymous (not verified) |
94.188.207.224 |
fixIT.fyi, LLC |
1243 Buchanan Ave, Sioux City, IA 51108 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-10 |
Daisy Larae Neuroth |
Daisy@fixIT.fyi |
Sioux City |
Woodbury |
Iowa |
Chad Neuroth |
Alice Bruns |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daisy Larae Neuroth |
Daisy@fixIT.fyi |
Owner/Same |
Sioux City |
Woodbury |
Iowa |
Chad Neuroth |
Alice Bruns |
Signed |
257 |
2021-05-05 14:36 |
Anonymous (not verified) |
208.38.228.41 |
NSENSE inc |
415 Stanton Ave. Suite 205 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-05 |
David A. Laird |
dalaird@n-sense.us |
Ames |
Story |
IA |
Raina Powell |
Josh Powell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Laird |
dalaird@n-sense.us |
President |
Ames |
Story |
IA |
Besta Pruski |
Marek Pruski |
Signed |
40 |
2020-02-14 09:22 |
Anonymous (not verified) |
50.83.38.221 |
Pa's Construction LLC |
2350 Glass RD NE |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-14 |
Daniel Saunders |
dan2112411@yahoo.com |
Cedar Rapids |
USA_IA |
USA_IA |
Walt Cheney |
Becky Cheney |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Saunders |
dan2112411@yahoo.com |
Owner- Manager |
Cedar Rapids |
USA_IA |
USA_IA |
Walt Cheney |
Becky Cheney |
Signed |
555 |
2022-10-06 17:48 |
Anonymous (not verified) |
67.22.198.94 |
Baker Irrigation inc |
2621 310th st |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-10-08 |
Daniel Brent Baker |
dan@bakerirrigationia.com |
ROCK VALLEY |
IA |
United States |
Adam Kooistra |
Alex De Jager |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Baker |
dan@bakerirrigationia.com |
President |
ROCK VALLEY |
IA |
United States |
Alex DeJager |
Adam Kooistra |
Signed |
558 |
2022-10-17 09:25 |
Anonymous (not verified) |
67.22.198.94 |
Baker Irrigation Inc. |
2621 310th St. Rock Valley, IA 51247 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-10-17 |
Daniel Baker |
dan@bakerirrigationia.com |
Rock Valley |
Sioux |
Iowa |
Jesse Niemeyer |
Crystal Brink |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Alex DeJager |
alex@bakerirrigationia.com |
Co-Owner |
Rock Valley |
Sioux |
Iowa |
Jesse Niemeyer |
Crystal Brink |
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 |
702 |
2023-06-27 07:04 |
Anonymous (not verified) |
94.188.207.230 |
Dancom Inc |
1001 Office Park Rd, West Des Moines, IA 50265 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-26 |
Daniel Otundo |
daniel@dancoms.com |
Waukee |
Polk |
IA |
Joe Meyers |
Robert Simmons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Otundo |
daniel@dancoms.com |
Owner |
Waukee |
Polk |
IA |
Robert Simmons |
Joe Meyers |
Signed |
586 |
2022-12-16 15:53 |
Anonymous (not verified) |
184.184.197.146 |
Halide Biologics |
330 Golfview Ave, Iowa City IA 52246 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-12-15 |
Daniel Infield |
danielinfield@gmil.com |
Bennington |
Douglas |
Nebraska |
Alexander Estell |
Jesse Herrera |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Infield |
danielinfield@gmail.com |
President |
Bennington |
NE |
United States |
Alexander Estell |
Jesse Herrera |
Signed |