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Rejection of Workers' Compensation or Employers' Liability Coverage

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# Submitted User IP address Name of Corporation: Address of Corporation Home Office: Statement 1 Agreement: Statement 2 Agreement: Statement 3 Agreement: Statement Agreement: Check Either Alternative (1) or (2): Date: Full Name of Individual: Email: City of Residence: County of Residence: State of Residence: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Agreement: Alternative Selection: Full Name of Authorized Agent: Email of Authorized Agent: Relationship to Corporation of Authorized Agent: City of Residence: County of Residence: State: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Indication:
986 2024-05-13 17:26 Anonymous (not verified) 94.188.207.229 Rail and Road Equipment Co 1797 G50 HWY. St. Charles, IA. 50240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-13 Ranae Pontier railandroad@myomnitel.com St Charles Warren IA Abbi Goering Travis Allen Signed (1) The corporation rejects the employers’ liability coverage. Ranae Pontier railandroad@myomnitel.com Vice President St Charles Warren IA Abbi Goering Travis Allen 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
323 2021-08-30 12:22 Anonymous (not verified) 173.19.179.111 OKOBOJI TREE SPECIALISTS II iNC PO BOX 515 MILFORD, IA 51351 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-13 THOMAS WRIGHT joel@walkerinsuranceia.com MILFORD DICKINSON IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The corporation rejects the employers’ liability coverage. THOMAS WRIGHT joel@walkerinsuranceia.com ADMIN ST PAUL MN 55106 JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
108 2020-08-19 09:39 Anonymous (not verified) 184.80.177.137 Michelle's Vocational Placement LLC 2642 Farragut Pl., Davenport, IA 52804 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-08-18 Tara Rommel jheims@engish-insurance.com Davenport Scott Iowa Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed
119 2020-09-28 10:43 Anonymous (not verified) 174.213.149.6 Ddp construction 1923 63rd st, des moines ,ia 50322 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-28 Dustin a perry perrythedustin@gmail.com Urbandale Polk Iowa Lucas jackson Cody roth Signed (1) The corporation rejects the employers’ liability coverage. Smith Kenyon insurance smithkenyon@yahoo.com Agent Urbandale Polk Ia Lucas jackson Cody roth Signed
129 2020-10-30 11:23 Anonymous (not verified) 184.80.177.137 Haberdash Outfitters, Inc. 109 1st Ave East - Dyersville, IA 52040 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-10-27 Jennifer Recker jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
144 2020-12-04 12:02 Anonymous (not verified) 184.80.177.137 Arlen, LLC 322 6th St SE - Dyersville, Iowa 52040 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-04 Dan Arlen jheims@english-insurance.com Dyersville IA IA Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Joyce Heims joyce.heims1@gmail.com agent Dyersville IA IA Derrick Parsons Joyce Heims Signed
263 2021-05-06 15:18 Anonymous (not verified) 174.243.113.232 Agronomic Solutions 908 E Dubuque St Quasqueton IA 52326 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-05-06 Brandy Hodges mapping@agsolutionsinc.net Coon Rapids IA United States Jacki Sloss Don Sloss Signed (1) The corporation rejects the employers’ liability coverage. Friday Insurance doug.miller@fridayinsurance.net agent Osceola Clarke IA Jacki Sloss Don Sloss Signed
384 2022-01-06 16:01 Anonymous (not verified) 184.80.177.137 Top R Farms 1199 Woodland Drive - Dyersville, IA 52040 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-06 Robert Fangmann jheims@english-insurance.com Dyersville Dubuque IA Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons jheims@english-insurance.com agent Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed
388 2022-01-11 13:58 Anonymous (not verified) 184.80.177.137 Demmer Construction 203 Michigan Ave - 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. 2021-12-21 Charlie Demmer jheims@english-insurance.com Dyersville Dubuque IA Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Jenny Osburn jheims@english-insurance.com agent Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed
389 2022-01-11 14:02 Anonymous (not verified) 184.80.177.137 Demmer Construction 203 Michigan Ave - 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. 2021-05-12 Charlie Demmer jheims@english-insurance.com Farley Dubuque Iowa Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Jenny Osburn jheims@english-insurance.com agent Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed
413 2022-02-23 16:31 Anonymous (not verified) 184.80.177.137 T-Rex Hospitality LLC, DBA FUSE 120 Twin Steeples Circle, Dyersville Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-23 Tara Rahe jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
436 2022-03-29 11:07 Anonymous (not verified) 184.80.177.137 Adam Sheppard 22194 260th St - Delhi, Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-24 Adam Sheppard jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Adam Sheppard jheims@english-insurance.com agent Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
448 2022-04-19 15:15 Anonymous (not verified) 184.80.177.137 Andrew Lemke DBA: TAP Fabrication 27214 218th Street, Earlville, IA 52041 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-08 Andrew Lemke jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
455 2022-04-27 14:04 Anonymous (not verified) 184.80.177.137 Classic Custom Cabinets, Inc 31931 Bries Drive , Dyersville, IA 52040 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-27 Mike Then jheims@english-insurance.com Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Joyce Heims jheims@english-insurance.com agent Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed
541 2022-09-23 13:13 Anonymous (not verified) 184.80.177.137 Tim & Lori Daly 25430 New Vienna Rd - 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. 2022-09-23 Tim Daly jheims@english-insurance.com Dyersville Dubuque IA Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque IA Derrick Parsons Joyce Heims Signed
639 2023-03-27 12:24 Anonymous (not verified) 94.188.207.230 Midwest Home Solutions Inc 150 Light Road, Lisbon, IA 52253 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or 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 Ean Caskey ean_caskey@hotmail.com Lisbon Linn IA Corey Scott Daniel Munro Signed (1) The corporation rejects the employers’ liability coverage. Daniel Munro danielmunro@gmail.com Agent Oceanside CA United States Corey Scott Daniel Munro Signed
647 2023-04-04 11:51 Anonymous (not verified) 94.188.207.225 Ibarra's Construction LLC 4125 56th Street Des Moines IA 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. 2023-04-04 Serafin Orendain Rivera serafinorivera334@gmail.com Des Moines Polk Iowa Saul Orendain Maricela Pillado Signed (2) The corporation declines to reject the employers’ liability coverage. Matt Thompson mthompson@urscompliance.com Agent Minneapolis Hennepin County MN Maricela Pillado Saul Orendain Signed
683 2023-06-09 14:03 Anonymous (not verified) 94.188.207.228 Fire & Ice Heating and Cooling 6040 114th St, Blue Grass IA 52726 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-09 Todd Ruckoldt ruckoldt1@icloud.com Blue Grass Scott Iowa Eric Ruckoldt Tyler Ruckoldt Signed (1) The corporation rejects the employers’ liability coverage. Javier Gonzalez javier@qcinsured.com Agent Davenport Scott Iowa Eric Ruckoldt Tyler Ruckoldt Signed
896 2024-02-23 16:14 Anonymous (not verified) 94.188.205.167 Convenience Stores Business Inc 1615 Bishop Ave, Waterloo, IA 50707 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2025-02-26 John Sarwar trampride@aol.com Waterloo Black Hawk IA . . Signed (1) The corporation rejects the employers’ liability coverage. Jason Koch jason_koch@veridiancu.org Agent Waterloo Black Hawk IA . . Signed
939 2024-04-01 11:44 Anonymous (not verified) 94.188.207.228 SFA INC 955 31ST MARION, IA 52302-3788 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-04-01 SARAH FERRETER sarah@sfacpa.com MARION LINN IOWA WILLIE CALDWELL ALEXANDRA BACHMAN Signed (1) The corporation rejects the employers’ liability coverage. WILLIE CALDWELL WILLIE.CALDWELL.B2SH@STATEFARM.COM AGENT CEDAR RAPIDS LINN IOWA WILLIE CALDWELL ALEXANDRA BACHMAN Signed
975 2024-05-06 14:30 Anonymous (not verified) 94.188.207.228 Plendl Farm Mangement LLC 4951 Harrison Ave, Maurice, IA 51036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-06 Christopher Plendl mcplendl@mtcnet.net Maurice Sioux IA Stacey Paulsen Austin Reitz Signed (1) The corporation rejects the employers’ liability coverage. Gerald Van Roekel gerald@veinsurance.com agent Orange City Sioux IA Stacey Paulsen Austin Reitz Signed
983 2024-05-11 12:27 Anonymous (not verified) 94.188.207.225 Aluminum King MFG LTD 700 E Van Buren St, Mitchell, IA 50461 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-11 Jeremy Mostek katie@flashingthunder.com Mitchell Mitchell IA Kristy Wolfe Tami Towne Signed (1) The corporation rejects the employers’ liability coverage. Tami Towne ttowne@ryderinsurance.com Agent Grand Island Hall NE Kristy Wolfe Katherine Mostek Signed
76 2020-05-04 10:24 Anonymous (not verified) 173.191.207.202 Tim Fitzgerald Mechanical Services, Inc. 724 1st Ave W - Dyersville, IA 52040 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-24 Tim Fitzgerald jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent-English Insurance Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
80 2020-05-11 12:29 Anonymous (not verified) 173.191.207.202 J&D Furniture-Land Corp 144 1st Ave East - Dyersville, IA 52040 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-05-07 Scott Hittenmiller dparsons@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Joyce Heims jheims@english-insurance.com agent-English Insurance Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
61 2020-04-20 13:13 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 Bruce Tamisiea jennifer@walkerinsuranceia.com Wahpeton Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Bruce Tamisiea jennifer@walkerinsuranceia.com Board Member Wahpeton Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
62 2020-04-20 13:18 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 Ron Morocco jennifer@walkerinsuranceia.com Milford Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Ron Morocco jennifer@walkerinsuranceia.com Board Member Milford Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
63 2020-04-20 13:23 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 Suzie Wilmot jennifer@walkerinsuranceia.com Minneapolis Hennepin Minnesota Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Suzie Wilmot jennifer@walkerinsuranceia.com Board Member Minneapolis Hennepin Minnesota Joseph Thomas Loring Jennifer Janet Youngwirth Signed
65 2020-04-20 13:37 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 Denny Walker jennifer@walkerinsuranceia.com West Okoboji Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Denny Walker jennifer@walkerinsuranceia.com Board Member West Okoboji Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
66 2020-04-20 13:41 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 Tresa Hussong jennifer@walkerinsuranceia.com Arnolds Park Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Tresa Hussong jennifer@walkerinsuranceia.com Board Member Arnolds Park Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
215 2021-03-29 07:58 Anonymous (not verified) 173.18.193.51 Lee County Fair, Inc PO Box 179 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-05 Dillon Benner judy@fullenkampins.com ARgyle IA United States Lindsey Lampe Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Dillon Benner judy@fullenkampins.com Board Member Argyle IA United States Lindsey Lampe Judy Moeller Signed
216 2021-03-29 08:01 Anonymous (not verified) 173.18.193.51 Lee County Fair, Inc PO Box 179, Donnellson, IOwa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-03 Bryan Bredemeyer judy@fullenkampins.com Bonaparte IA United States Lindsey Lampe Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Brian Bredemeyer judy@fullenkampins.com Board Member Bonaparte IA United States Lindsey Lampe Judy Moeller Signed
217 2021-03-29 08:03 Anonymous (not verified) 173.18.193.51 Lee County Fair, Inc PO Box 179, Donnellson, Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-23 Erin Wagnoer judy@fullenkampins.com Donnellson Lee Iowa Lindsey Lampe Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Erin Wagner judy@fullenkampins.com Board Member donnellson Lee Iowa Lindsey Lampe Judy Moeller Signed
218 2021-03-29 08:04 Anonymous (not verified) 173.18.193.51 Lee County Fair, Inc PO Box 179, Donnellson, Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-03 Matthew Wilson judy@fullenkampins.com Donnellson Lee Iowa Lindsey Lampe Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Matthew Wilson judy@fullenkampins.com Board Member Donnellson Lee Iowa l0 Judy Moeller Signed
219 2021-03-29 08:05 Anonymous (not verified) 173.18.193.51 Lee County Fair, Inc PO Box 179, Donnellson, Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-03 Brock Westfall judy@fullenkampins.com Montrose Lee Iowa Lindsey Lampe Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Brock Westfall judy@fullenkampins.com Board Member Montrose Lee Iowa Lindsey Lampe Judy Moeller Signed
220 2021-03-29 08:07 Anonymous (not verified) 173.18.193.51 Lee County Fair, Inc PO Box 179, Donnellson, Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-23 David Hoenig judy@fullenkampins.com Fort Madison Lee Iowa Lindsey Lampe Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. David Hoenig judy@fullenkampins.com Board member Fort Madison Lee Iowa Lindsey Lampe Judy Moeller Signed
223 2021-03-29 08:11 Anonymous (not verified) 173.18.193.51 Lee County Fair, Inc PO Box 179, Donnellson, Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-04 Tammy LeMaster judy@fullenkampins.com Argyle Lee iowa Lindsey Lampe Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Tammy LeMaster judy@fullenkampins.com Board Member ARgyle Lee Iowa Lindsey Lampe Judy Moeller Signed
228 2021-04-05 13:06 Anonymous (not verified) 173.18.193.51 Houghton Cedar Township Fire Department 1135 140th Avenue, Salem, Iowa 52649 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-03 Brad Vandenberg judy@fullenkampins.com Donnellson Lee Iowa Judy Moeller Shelby Green Signed (1) The corporation rejects the employers’ liability coverage. Brad Vandenberg judy@fullenkampins.com Board Member Salem Lee Iowa Judy Moeller Shelby Green Signed
229 2021-04-05 13:44 Anonymous (not verified) 173.18.193.51 Denmark Sanitary District PO Box 141, Denmark, Iowa 52624 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-03 Clay Fullenkamp judy@fullenkampins.com West Point Lee Iowa Judy Moeller Brian Stuekerjuergen Signed (2) The corporation declines to reject the employers’ liability coverage. Clay Fullenkamp judy@fullenkampins.com Board Member West Point Lee Iowa judy moeller brian stuekerjuergen Signed
482 2022-06-02 08:25 Anonymous (not verified) 173.18.193.51 Wever Fire Association 1692 354th Avenue, Wever, Iowa 52658 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-24 Bill Brookhiser judy@fullenkampins.com Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Bill Brookhiser judy@fullenkampins.com Board Member Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed
485 2022-06-02 08:33 Anonymous (not verified) 173.18.193.51 Wever Fire Association 1692 354th Avenue, Wever, Iowa 52658 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-24 Hugh Vandgriff judy@fullenkampins.com Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Hugh Vandegriff Judy@fullenkampins.com board member Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed
487 2022-06-02 08:36 Anonymous (not verified) 173.18.193.51 Wever Fire Association 1692 354th Avenue, Wever, Iowa 52658 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-25 Jacob Denning judy@fullenkampins.com Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Jacob Denning judy@fullenkampins.com Board Member Wever Lee Iowa Chris Fullenkamp Judy Moeller 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
287 2021-07-19 11:58 Anonymous (not verified) 207.199.222.199 STEPHEN MEMORIAL ANIMAL SHELTER INC 1716 Pella 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. 2021-06-26 Jeanie Bieri jeanie.bieri@musco.com Oskaloosa Mahaska Iowa Billy Blake Merri Chris Hawker Signed (1) The corporation rejects the employers’ liability coverage. Jeanie Bieri jeanie.bieri@musco.com Board President Oskaloosa Mahaska Iowa Billy Blake Merri Chris Hawker Signed
269 2021-05-25 20:25 Anonymous (not verified) 174.71.12.114 The Town and Country Aqua Club of Council Bluffs 15444 Cherry Tree Lane 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. 2021-05-25 David Alan Bergman dbrgmn@gmail.com Council Bluffs Iowa United States Brett Ford Sean Dunphy Signed (1) The corporation rejects the employers’ liability coverage. David Alan Bergman dbrgmn@gmail.com Board Vice President Council Bluffs Iowa United States Brett Ford Sean Dunphy Signed
704 2023-06-30 11:09 Anonymous (not verified) 94.188.205.174 KLS Meter Services, LLC 1000 Woodbury 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. 2023-06-29 Kevin Schrage kls2021@yahoo.com Council Bluffs Pottawattamie IA Stephan Nelson Miriam Martinez Signed (1) The corporation rejects the employers’ liability coverage. David E Pike Stephan@pikeinsuranceservices.com Broker Oceanside California CA Stephan Nelson Miriam Martinez Signed
100 2020-07-14 19:08 Anonymous (not verified) 208.90.8.234 Humboldt County Agricultural 311 N 6th Ave, P.O. Box 391, Humboldt, IA 50548 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-07-18 Jeff Haselhuhn gjhaselhuhn@gmail.com Humboldt Humboldt IA Marva Anderson Jeff Halverson Signed (1) The corporation rejects the employers’ liability coverage. Marva Anderson info@humboldtcountyfair.com Business Manager Humboldt 81 81 Marva Anderson Jeff Halverson Signed
102 2020-07-19 14:42 Anonymous (not verified) 208.90.8.234 Humboldt County Agricultural Society 311 N 6th Ave P.O. Box 391, Humboldt, IA 50548 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-07-19 Paul Davis dfs72@yahoo.com Humboldt Humboldt IA Marva Anderson Paul Davis Signed (1) The corporation rejects the employers’ liability coverage. Humboldt County Agricultural Society info@humboldtcountyfair.com Business Manager Humboldt 81 IA Marva Anderson Jeff Halverson Signed
105 2020-07-24 18:21 Anonymous (not verified) 74.115.101.23 Humboldt County Agricultural Society 311 N 6th Ave P.O. Box 391, Humboldt, IA 50548 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-07-24 Kevin Cordray kwcordray@gmail.com Humboldt Humboldt IA Marva Anderson Jeff Halverson Signed (1) The corporation rejects the employers’ liability coverage. Humboldt County Agricultural Society info@humboldtcountyfair.com Business Manager Humboldt Humboldt IA Marva Anderson Jeff Halverson Signed
786 2023-10-16 07:27 Anonymous (not verified) 94.188.207.230 Aurora Aesthetics and Functional Medicine LLC 713 1st Ave NW I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-04 Meagan Mclaughlin meagan.vitae@gmail.com Mount Vernon IA United States Michael Friess Stephanie Friess Signed (1) The corporation rejects the employers’ liability coverage. Michael Friess Aurorafunctionalmed@gmail.com business manager Mt Vernon IA United States Stephanie Friess Meagan Friess Signed
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
235 2021-04-14 13:18 Anonymous (not verified) 173.31.147.225 HISTORIC ARNOLDS PARK INC 37 LAKE ST ARNOLDS PARK, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-14 LANCE EVANS joel@walkerinsuranceia.com ARNOLDS PARK DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The corporation rejects the employers’ liability coverage. JEFF VIERKANT Jeff@arnoldspark.com CEO SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JEFF VIERKANT Signed
335 2021-09-16 17:22 Anonymous (not verified) 64.142.5.50 Electrious Inc DBA Clean Tech 1110 Alhambra Ave Martinez CA 94533. I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-26 Robert Lemos robbie.lemos@clean.tech San Ramon Contra Costa County CA Teresa Leibnitz Greg Vermeulen Signed (1) The corporation rejects the employers’ liability coverage. Robbie Lemos robbie.lemos@clean.tech CEO San Ramon Contra Costa County CA Teresa Leibnitz Greg Vermeulen Signed
336 2021-09-16 18:53 Anonymous (not verified) 64.142.5.50 Electrious Inc DBA Clean Tech 1110 Alhambra Ave Martinez CA 94533. I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-26 Petr Brazdil petr.brazdil@clean.tech Trida Spojencu Brno Czechia in Europe Robbie Lemos Teresa Leibnitz Signed (1) The corporation rejects the employers’ liability coverage. Robbie Lemos robbie.lemos@clean.tech CEO SAN RAMON Contra Costa County CA Robbie Lemos Teresa Leibnitz Signed
361 2021-11-15 18:08 Anonymous (not verified) 199.66.15.123 Wills Work 302 N Kenwood Blvd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-11-15 Timothy Williams Robinson williamswork18@gmail.com Indianola Warren Iowa Andrew Gilbert Barber Sarah Anne Robinson Signed (1) The corporation rejects the employers’ liability coverage. Timothy Will Robinson williamswork18@gmail.com CEO Indianola Warren Iowa Andrew Gilbert Barber Sarah Anne Robinson Signed
491 2022-06-06 09:32 Anonymous (not verified) 24.118.76.144 Minnesota Restoration Contractors Inc. DBA MNRC 12252 Nicollet Ave Burnsville, MN 55337 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-06 Daniel Lewis Lillestol info@mnrcinc.com Wayzata MN United States Karina Bazhenova MICHELLE LILLESTOL Signed (1) The corporation rejects the employers’ liability coverage. Daniel Lewis Lillestol info@mnrcinc.com CEO Wayzata Hennnepin MN Karina Bazhenova MICHELLE LILLESTOL Signed
498 2022-06-17 08:45 Anonymous (not verified) 64.5.79.180 The Sign Shed & Graphics LLC 529 Erie St, PO Box 252 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or 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 Brent Ulrich signshed@yahoo.com Storm Lake IA United States Zach Ruroden Ryan Young Signed (1) The corporation rejects the employers’ liability coverage. Brent Ulrich signshed@yahoo.com CEO Storm Lake IA United States Zach Ruroden Ryan Young Signed
501 2022-06-24 12:10 Anonymous (not verified) 173.31.148.43 HISTORIC ARNOLDS PARK INC 37 LAKE ST ARNOLDS PARK, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2022-06-24 JON PAUSLEY JON@ARNOLDSPARK.COM MILFORD DICKINSON IOWA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (2) The corporation declines to reject the employers’ liability coverage. JON PAUSLEY JON@ARNOLDSPARK.COM CEO MILFORD DICKINSON IOWA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
502 2022-06-24 12:15 Anonymous (not verified) 173.31.148.43 HISTORIC ARNOLDS PARK INC 37 LAKE ST ARNOLDS PARK, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-24 GARY RAY GARYJRAY70@GMAIL.COM SPIRIT LAKE DICKINSON IOWA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The corporation rejects the employers’ liability coverage. JON PAUSLEY JON@ARNOLDSPARK.COM CEO MILFORD DICKINSON IOWA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
536 2022-09-16 09:56 Anonymous (not verified) 65.155.194.4 Tectum Construction and Roofing Inc. 1623 Thetford Cir Orlando FL 32824 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-16 Segundo Sanchez fsanchez@tectumconstruction.com Orlando Fl United States Chris Becker Dereck Bolten Signed (1) The corporation rejects the employers’ liability coverage. Segundo Sanchez fsanchez@tectumconstruction.com CEO ORLANDO Orange Florida Chris Becker Dereck Bolten Signed
637 2023-03-23 15:53 Anonymous (not verified) 94.188.207.229 Pacifica Health Services, LLC 4911 SW 19th St, Des Moines, IA 50315 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-23 Jennifer Conner jconner@viahealthservices.com Des Moines Polk IA Jackie Hastings Amber Perdue Signed (1) The corporation rejects the employers’ liability coverage. Kevin Babb kbabb@viahealthservices.com CEO Waukee Dallas IA Jackie Hastings Amber Perdue Signed
594 2023-01-31 09:17 Anonymous (not verified) 70.58.136.161 Great Tree LLC 2701 e douglas ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-31 Robert buell Greattree55@gmail.com Des Moines IA United States Jamarlo alvarez Fields Amanda lee netolicky Signed (1) The corporation rejects the employers’ liability coverage. Robert buell Greattree55@gmail.com ceo/ company owner/ operator Des Moines IA United States Jamarlo Alvarez Fields Amanda Lee Netolicky Signed
559 2022-10-24 15:14 Anonymous (not verified) 108.178.192.251 LogicBox, Inc. 2381 Highway 169, 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. 2022-10-24 Jeremy Goemaat jeremy.goemaat@gmail.com Winterset Madison Iowa Janelle Goemaat Gunnar Goemaat Signed (1) The corporation rejects the employers’ liability coverage. Jeremy Goemaat jeremy.goemaat@gmail.com CEO/Owner Winterset Madison Iowa Janelle Goemaat Gunnar Goemaat Signed
117 2020-09-11 11:54 Anonymous (not verified) 162.218.1.22 american business resource corporation 4600 American Parkway Suite #301 Madison, WI 53718 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or 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 Michelle Szabrowicz mszabrowicz@abrjobs.com Madison Dane Wisconsin Patricia Haggerty Britney Mollet Signed (1) The corporation rejects the employers’ liability coverage. Michelle Szabrowicz mszabrowicz@abrjobs.com CFO Madison Dane Wisconsin Patricia Haggerty Britney Mollet Signed
603 2023-02-16 16:11 Anonymous (not verified) 94.188.207.223 Transcend Mind Body Wellness and Floatation Clinic 409 Washington Street, Cedar Falls, IA 50613 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-01 Morgan Huls transcendcedarfalls@gmail.com Cedar Falls Black Hawk Iowa Brady Huls Ashlyn Henry Signed (1) The corporation rejects the employers’ liability coverage. Brady Huls transcendcfo@gmail.com CFO Cedar Falls Black Hawk Iowa Morgan Huls Ashlyn Henry Signed
918 2024-03-11 14:29 Anonymous (not verified) 94.188.207.224 DeJear Inc. 3220 SW 34th Street, Des Moines, Iowa 50321 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-11 Marvin L. DeJear Jr marvin.dejear@gmail.com Des Moines Polk Iowa Rory Robson Geoff Matlock Signed (1) The corporation rejects the employers’ liability coverage. Marvin L. DeJear Jr dejear@dejearcorporation.com Chief Administrative Officer Des Moines Polk Iowa Rory Robson Geoff Matlock Signed
919 2024-03-11 14:32 Anonymous (not verified) 94.188.207.226 DeJear Inc. 3220 SW 34th Street, Des Moines, Iowa 50321 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-11 Deidre Olivia DeJear deidre.dejear@gmail.com Des Moines Polk Iowa Rory Robson Geoff Matlock Signed (1) The corporation rejects the employers’ liability coverage. Marvin Leo DeJear Jr dejear@dejearcorporation.com Chief Administrative Officer Des Moines Polk Iowa Rory Robson Geoff Matlock Signed
545 2022-09-29 08:59 Anonymous (not verified) 208.126.212.128 City of Leland 316 Walnut St., Leland, IA 50453 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-29 Marsha Casler mandrcasler@hotmail.com Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed (1) The corporation rejects the employers’ liability coverage. Dawn Arispe leland@wctatel.net City Clerk of Leland Leland Iowa United States Roger Torkelson Kelly Bendickson Signed
546 2022-09-29 09:02 Anonymous (not verified) 208.126.212.128 City of Leland 316 Walnut St., PO Box 127 Leland, IA 50453 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-29 Susan Krein skkrein@gmail.com Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed (1) The corporation rejects the employers’ liability coverage. Dawn Arispe leland@wctatel.net City of Leland City Clerk Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed
547 2022-09-29 09:04 Anonymous (not verified) 208.126.212.128 City of Leland 316 Walnut St., PO Box 127, Leland, IA 50453 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-29 Ken Steil leland@wctatel.net Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed (1) The corporation rejects the employers’ liability coverage. Dawn Arispe leland@wctatel.net City of Leland City Clerk Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed
548 2022-09-29 09:06 Anonymous (not verified) 208.126.212.128 City of Leland 316 Walnut St., PO Box 127, Leland, IA 50453 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-29 Rex Johnson rexr@wctatel.net Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed (1) The corporation rejects the employers’ liability coverage. Dawn Arispe leland@wctatel.net City of Leland City Clerk Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed
549 2022-09-29 09:08 Anonymous (not verified) 208.126.212.128 City of Leland 316 Walnut St., PO Box 127, Leland, IA 50453 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-29 Jesse O'Toole jesseotoole7@gmail.com Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed (1) The corporation rejects the employers’ liability coverage. Dawn Arispe leland@wctatel.net City of Leland City Clerk Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed
550 2022-09-29 09:10 Anonymous (not verified) 208.126.212.128 City of Leland 316 Walnut St., PO Box 127, Leland, IA 50453 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-29 Russell Leitz rkleitz@wctatel.net Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed (1) The corporation rejects the employers’ liability coverage. Dawn Arispe leland@wctatel.net City of Leland City Clerk Leland Winnebago Iowa Roger Torkelson Kelly Bendickson 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
315 2021-08-19 13:08 Anonymous (not verified) 173.26.33.84 CLINK FM, Inc. 110 N. Maryville 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. 2021-08-19 Kyana B Taillon kyanalily@gmail.com Oelwein Fayette IA Della Nehring Tim Nehring Signed (1) The corporation rejects the employers’ liability coverage. Jesse Y Goplen jesse@clink.fm Co-Founder/President Oelwein Fayette IA Della Nehring Tim Nehring Signed
314 2021-08-19 12:58 Anonymous (not verified) 173.26.33.84 CLINK FM, INC. 110 N. Maryville Street, Calmar, IA 52132 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-19 Jesse Y Goplen jessegoplen@gmail.com Oelwein Fayette IA Della Nehring Tim Nehring Signed (1) The corporation rejects the employers’ liability coverage. Kyana Taillon kyana@clink.fm Co-Founder/Vice-President Oelwein Fayette IA Della Nehring Tim Nehring Signed
151 2021-01-01 11:26 Anonymous (not verified) 75.162.130.160 The Product Boss LLC 20 Mountain Way, West Orange, NJ 07052 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-01 Minna Khounlo-Sithep minna@theproductboss.com Ankeny IA IA Nalinh Sithep Suzzan Khounlo Signed (1) The corporation rejects the employers’ liability coverage. Minna Khounlo-Sithep minnaks@gmail.com Co-Owner Ankeny IA IA Nalinh Sithep Suzzan Khounlo Signed
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
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
628 2023-03-21 12:07 Anonymous (not verified) 94.188.207.226 Deep Cleaning Janitorial Inc 3131 33rd Ave SW Ceder Rapids IA 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-21 Paul Mwai deepcleaning0142@gmail.com Cedar Rapids IA United States Mary Ngotho John Johnson Signed (1) The corporation rejects the employers’ liability coverage. Ray Robertson deepcleaning0142@gmail.com Co-Owner Cedar Rapids Linn United States John Johnson Mary Ngotho Signed
629 2023-03-21 12:14 Anonymous (not verified) 94.188.207.230 Deep Cleaning Janitorial Inc 3131 33rd Ave SW Ceder Rapids IA 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-21 Ray Robertson deepcleaning0142@gmail.com Cedar Rapids linn United States Shelley Robertson William Robertson Signed (1) The corporation rejects the employers’ liability coverage. Paul Mwai deepcleaning0142@gmail.com Co-Owner Cedar Rapids Linn IA Shelley Robertson William Robertson Signed
630 2023-03-21 21:32 Anonymous (not verified) 94.188.205.169 S & O Builders, LLC 201 NW 10th Circle, Grimes, IA 50111 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-21 Benjamin Olson sandobuilders@gmail.com Grimes IA IA Brad Fasse Nate Estes Signed (1) The corporation rejects the employers’ liability coverage. Benjamin Olson sandobuilders@gmail.com Co-Owner Grimes IA IA Brad Fasse Nate Estes Signed
650 2023-04-10 13:06 Anonymous (not verified) 94.188.205.168 Deep Cleaning Janitorial Inc 3131 33rd Ave SW Ceder Rapids IA 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-04-11 Paul Mwai deepcleaning0142@gmail.com Cedar Rapids IA United States Mary Ngotho John Johnson Signed (1) The corporation rejects the employers’ liability coverage. Ray Robertson deepcleaning0142@gmail.com Co-Owner Cedar Rapids Linn United States Shelley Robertson William Robertson Signed
651 2023-04-10 13:21 Anonymous (not verified) 94.188.205.175 Deep Cleaning Janitorial Inc 3131 33rd Ave SW Ceder Rapids IA 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-04-10 Ray Robertson deepcleaning0142@gmail.com Cedar Rapids IA United States Shelley Robertson William Robertson Signed (1) The corporation rejects the employers’ liability coverage. Paul Mwai deepcleaning0142@gmail.com Co-Owner Cedar Rapids Linn United States Mary Ngotho John Johnson Signed
654 2023-04-18 11:13 Anonymous (not verified) 94.188.205.168 Moon & Pasutti Tile, LLC 3501 SW 9th 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. 2023-04-18 Robert Michael Pasutti robpasutti@gmail.com Des Moines Polk IA Sharon Marie Pasutti Michael Anthony Daniel Pasutti Signed (1) The corporation rejects the employers’ liability coverage. Robert Michael Pasutti robpasutti@gmail.com Co-Owner Des Moines Polk IA Sharon Marie Pasutti Michael Anthony Daniel Pasutti Signed
824 2023-11-21 13:22 Anonymous (not verified) 94.188.207.227 OhZone. LLC 852 Washington Street Burlington, IA 52601 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-19 Jeffery W Ishmael jeffishmael@gmail.com Des Moines IA United States Juan DeLlanos Gregory Gunter Signed (1) The corporation rejects the employers’ liability coverage. Jeffery W Ishmael jeffishmael@gmail.com Co-Owner Des Moines IA United States Juan DeLlanos Gregory Gunter Signed
936 2024-03-30 16:41 Anonymous (not verified) 94.188.205.176 Rhubarb Botanicals LLC 650 Martelle Rd, Springville IA 52336 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-30 Emma Barber emma@rhubarbbotanicals.com Springville Linn Iowa Lena Wilhelm Harvey Wilhelm Signed (1) The corporation rejects the employers’ liability coverage. Emma Barber emma@rhubarbbotanicals.com Co-Owner Springville Linn Iowa Lena Wilhelm Harvey Wilhelm Signed
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
51 2020-03-30 11:01 Anonymous (not verified) 45.42.5.219 Iowa Roofpros 104 Anderson Street, Maquoketa, IA 52060 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-03-17 Heather Nienke heather@nienkesolar.com Maquoketa Jackson Iowa Derrick Parsons Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. Heather Nienke heather@nienkesolar.com Co-owners Maquoketa Jackson Iowa Derrick Parsons Brenda Lewis Signed
52 2020-03-30 11:04 Anonymous (not verified) 45.42.5.219 Iowa Roofpros 104 Anderson Street, Maquoketa, IA 52060 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-03-17 Jamison Nienke iowaroofguru@gmail.com Maquoketa Jackson Iowa Derrick Parsons Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. Jamison Nienke iowaroofguru@gmail.com Co-owners Maquoketa Jackson Iowa Derrick Parsons Brenda Lewis Signed
53 2020-03-30 11:09 Anonymous (not verified) 45.42.5.219 Taylor's Tri-State Construction 660 Tanzanite Drive, Dubuque, IA 52001 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-03-06 John Taylor taylorsconstruction78@yahoo.com Dubuque Dubuque Iowa Brenda Lewis Jessica Stepp Signed (1) The corporation rejects the employers’ liability coverage. John Taylor taylorsconstruction78@yahoo.com Co-owners Dubuque Dubuque Iowa Brenda Lewis Jessica Stepp Signed
680 2023-06-06 16:43 Anonymous (not verified) 94.188.205.167 Great Tree LLC 2701 e douglas ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-06 Timothy william Buell tbuell52@gmail.com Des Moines IA United States tyler smith Jamarlo fields Signed (1) The corporation rejects the employers’ liability coverage. Robert buell Greattree55@gmail.com company owner Des Moines IA United States jamarlo fields tyler Smith Signed
920 2024-03-18 15:42 Anonymous (not verified) 94.188.207.223 Great Tree LLC 2701 e douglas ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-18 Robert buell Greattree55@gmail.com Des Moines IA United States ryan homan Jamarlo fields Signed (1) The corporation rejects the employers’ liability coverage. Robert buell Greattree55@gmail.com company owner Des Moines IA United States ryan homan jamarlo fields Signed
921 2024-03-18 15:45 Anonymous (not verified) 94.188.207.226 Great Tree LLC 2701 e douglas ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-18 Timothy Buell treeshark52@gmail.com Des Moines IA United States ryan homan Jamarlo fields Signed (1) The corporation rejects the employers’ liability coverage. Robert buell Greattree55@gmail.com company owner Des Moines IA United States ryan homan jamarlo fields Signed
98 2020-07-11 16:34 Anonymous (not verified) 50.83.184.81 Paradigm Construction LLC 1847 nw 90th st 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. 2020-07-06 Jonathon Richard Curtis joncurtis15@gmail.com Des Moines Polk IA Yolanda Curtis Susan Brooker Signed (2) The corporation declines to reject the employers’ liability coverage. Ryan Shabino ryan@prdgmconstruction.com Contractor Clive Polk IA Yolanda Curtis Susan Brooker Signed
400 2022-02-04 10:37 Anonymous (not verified) 173.16.199.106 Paradigm Construction 960 Pelican Drive – Polk City, IA 50226 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-04 MATTHEW HENDRICKSON matthendrickson88@gmail.com NORWALK IA United States Richard Green Sheldon Thompson Signed (1) The corporation rejects the employers’ liability coverage. Ryan Shabino ryan@prdgmconstruction.com Contractor 960 Pelican Drive – Polk City, IA 50226 Polk Iowa Richard Green Sheldon Thompson Signed
622 2023-03-08 13:40 Anonymous (not verified) 94.188.207.226 DDD Construction 624 west maple P.O.164 Allerton I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-08 Douglas Dean Downs tripledconstruction@hotmail.com ALLERTON IA United States June Lynette Downs William Lee Downs Signed (1) The corporation rejects the employers’ liability coverage. Douglas Dean Downs tripledconstruction@hotmail.com Coowner ALLERTON IA United States June Lynette Downs William Lee Downs Signed
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
572 2022-11-17 16:43 Anonymous (not verified) 204.16.59.133 Washland, Inc. 4050 W Schrock Rd, Hudson, IA 50643 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-17 Steven Douglas Barfels getclean@laundryplusiowa.com Hudson Black Hawk Iowa Joel Steven Barfels Vicki Lorraine Barfels Signed (1) The corporation rejects the employers’ liability coverage. Joel Steven Barfels joel@laundryplusiowa.com Corporate Secretary Hudson Black Hawk Iowa Joel Steven Barfels Vicki Lorraine Barfels Signed
573 2022-11-17 16:46 Anonymous (not verified) 204.16.59.133 Washland, Inc. 4050 W Schrock Rd, Hudson, IA 50643 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-17 Vicki Lorraine Barfels vicki@laundryplusiowa.com Hudson Black Hawk Iowa Joel Steven Barfels Steven Douglas Barfels Signed (1) The corporation rejects the employers’ liability coverage. Joel Steven Barfels joel@laundryplusiowa.com Corporate Secretary Hudson Black Hawk Iowa Joel Steven Barfels Steven Douglas Barfels Signed
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
574 2022-11-17 16:48 Anonymous (not verified) 204.16.59.133 Washland, Inc. 4050 W Schrock Rd, Hudson, IA 50643 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-17 Joel Steven Barfels joel@laundryplusiowa.com Hudson Black Hawk Iowa Vicki Lorraine Barfels Steven Douglas Barfels Signed (1) The corporation rejects the employers’ liability coverage. Vicki Lorraine Barfels vicki@laundryplusiowa.com Corporate Treasurer Hudson Black Hawk Iowa Vicki Lorraine Barfels Steven Douglas Barfels Signed
566 2022-11-14 17:50 Anonymous (not verified) 107.77.206.66 JGR Carpentry 1305 N 6th St Apt. 11 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or 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 Josiah Grant Robinson grantyboy87@yahoo.com Indianola Warren Iowa Timothy William Robinson Austin Micheal Ross Signed (1) The corporation rejects the employers’ liability coverage. Josiah Grant Robinson grantyboy87@yahoo.com Corporation President Indianola Warren Iowa Timothy William Robinson Austin Micheal Ross Signed
33 2020-01-15 10:31 Anonymous (not verified) 216.161.118.103 ELOHIM HOME CARE AND STAFFING AGENCY, INC 301 NE Trilein Dr , ste 4B, Ankeny IA 50021 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-01-15 NITEZEHO NIYOMUGABO john@elohimhcs.com Ankeny Iowa United States john Tez Sem R Signed (1) The corporation rejects the employers’ liability coverage. John Tez john@elohimhcs.com Director Ankeny IA United States John Tez Tez Signed
118 2020-09-15 14:32 Anonymous (not verified) 174.243.115.133 Jurisdiction Approved Plumbing Corporation P.O. Box 343 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-15 Christian m Lavia eeejumble@gmail.com Urbandale Polk Iowa Tina m Heuckendorf Roslyn Heuckendorf Signed (1) The corporation rejects the employers’ liability coverage. Christian m Lavia eeejumble@gmail.com Director Urbandale Polk IOWA Tina m Heuckendorf Roslyn Heukendorf Signed
204 2021-03-08 10:43 Anonymous (not verified) 151.147.196.21 Iowa Gold Distributing, Inc. 600 Iehl Street, Central City, IA 52214 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation 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. 2021-02-10 Brad Coates igdenv@aol.com Central City Linn Iowa William Walters Jennifer Leinen Signed (2) The corporation declines to reject the employers’ liability coverage. Brad Coates igdenv@aol.com Director Central City Linn Iowa William Walters Jennifer Leinen Signed
256 2021-05-05 08:04 Anonymous (not verified) 206.127.178.33 NSense, Inc. 415 Stanton Ave Suite 205, Ames, IA 50014 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-05-05 Stephen R Ringlee sringlee@n-sense.us Ames Story Iowa Constance J. Ringlee Robert Anders Signed (1) The corporation rejects the employers’ liability coverage. Stephen R Ringlee sringlee@n-sense.us Director Ames Story Iowa Constance J Ringlee Robert Anders Signed
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
437 2022-03-29 14:03 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 Mersad Bosnic mersadbosnic@yahoo.com Urbandale Polk Iowa Mersad Bosnic Andy Swanson Signed (1) The corporation rejects the employers’ liability coverage. Andy Swanson sanienterprise14@gmail.com Director of Operations Granger Dallas Iowa Andrew Swanson Sandro Tadic 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
466 2022-05-09 10:52 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. 2022-05-09 Claude Riley Rileybuddy58@gmail.com Johnston Polk Iowa Andrew Swanson Claude Riley 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
467 2022-05-09 10:54 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. 2022-05-09 Safet Derguti safetigo@hotmail.com Des Moines Polk Iowa Andrew Swanson Sandro Tadic 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
663 2023-05-03 12:53 Anonymous (not verified) 94.188.205.177 Seven Oaks Recreation 1086 222nd Dr., Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-03 Joel Bryan joel@sevenoaksrec.com Ogden Boone United States Anthony Calek Craig Christensen Signed (1) The corporation rejects the employers’ liability coverage. Sara Bryan sara@sevenoaksre.com Director/Vice-President/Secretary Boone Boone United States Anthony Calek Craig Christensen Signed
664 2023-05-03 12:54 Anonymous (not verified) 94.188.205.174 Seven Oaks Recreation 1086 222nd Dr., Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-03 Sara Bryan sara@sevenoaksrec.com Ogden Boone Iowa Anthony Calek Craig Christensen Signed (1) The corporation rejects the employers’ liability coverage. Sara Bryan sara@sevenoaksre.com Director/Vice-President/Secretary Boone Boone United States Anthony Calek Craig Christensen Signed
665 2023-05-03 12:54 Anonymous (not verified) 94.188.205.169 Seven Oaks Recreation 1086 222nd Dr., Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-03 Joel Bryan joel@sevenoaksrec.com Ogden Boone Iowa Anthony Calek Craig Christensen Signed (1) The corporation rejects the employers’ liability coverage. Sara Bryan sara@sevenoaksre.com Director/Vice-President/Secretary Boone Boone United States Anthony Calek Craig Christensen Signed
748 2023-08-20 14:18 Anonymous (not verified) 94.188.205.177 NexLevelMoving 1186 capital dr sw I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2023-08-16 Ethan Daniel Sailer ethan.sailer@hscsi.net Cedar Rapids Linn County Iowa Denis Sailer Penny Sailer Signed (2) The corporation declines to reject the employers’ liability coverage. Tarin Erenberger tarin.nexlevelmoving@gmail.com Employee Cedar Rapids Linn County Iowa Taj Barrett Taj Barrett Signed
855 2024-01-17 14:55 Anonymous (not verified) 94.188.205.177 NexLevel Moving 5634 Deerwood Dr Sw I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-17 LaPriest Green lapriestg@gmail.com Cedar Rapids Linn County Iowa Adam Feldmann LaPriest Green Signed (1) The corporation rejects the employers’ liability coverage. LaPriest Green lapriestg@gmail.com Employee Cedar Rapids Linn County Iowa Adam Feldmann LaPriest Green Signed
856 2024-01-17 15:09 Anonymous (not verified) 94.188.205.167 Nex Level Moving, LLC 5634 Deerwood Dr SW I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-17 LaPriest Green lapriestg@gmail.com Cedar Rapids Linn County Iowa Adam Feldmann LaPriest Green Signed (1) The corporation rejects the employers’ liability coverage. LaPriest Green lapriestg@gmail.com Employee Cedar Rapids Linn County Iowa Adam Feldmann LaPriest Green Signed
333 2021-09-14 14:53 Anonymous (not verified) 147.0.156.50 O'Danny Boy Builders, Inc. 7512 S. County Line Rd., Suite #4, Burr Ridge, IL 60527 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-14 Daniel Flanagan jflanagan@odannyboybuilders.com LaGrange Cook Illinois John Flanagan Mark Hayes Signed (1) The corporation rejects the employers’ liability coverage. John Flanagan Jflanagan@odannyboybuilders.com Executive Western Springs Cook IL Ben Weed Mark Hayes Signed
516 2022-07-19 15:43 Anonymous (not verified) 66.207.21.24 Frank Iliff 1424 B Houser Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-22 Frank Iliff rtmuscatine@gmail.com Muscatine IA United States Dewayne Hopkins James R. Bell Signed (1) The corporation rejects the employers’ liability coverage. Frank Iliff rtmuscatine@gmail.com Executive Director Muscatine IA United States Dewayne Hopkins James R. Bell Signed
517 2022-07-19 15:43 Anonymous (not verified) 66.207.21.24 Frank Iliff 1424 B Houser Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-22 Frank Iliff rtmuscatine@gmail.com Muscatine IA United States Dewayne Hopkins James R. Bell Signed (1) The corporation rejects the employers’ liability coverage. Frank Iliff rtmuscatine@gmail.com Executive Director Muscatine IA United States Dewayne Hopkins James R. Bell Signed
532 2022-09-07 12:42 Anonymous (not verified) 217.180.226.147 Practical Farmers of Iowa 1615 Golden Aspen Dr., Suite 101, Ames, IA 50010 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-07 Jonathan Bakehouse jon@mapleedgefarm.com Hastings Mills Iowa Jeanne-Marie Bakehouse DeWayne Kroledge Signed (1) The corporation rejects the employers’ liability coverage. Sally Worley sally@practicalfarmers.org Executive Director Ames Story United States Jeann-Marie Bakehouse DeWayne Kroledge Signed
684 2023-06-13 08:54 Anonymous (not verified) 94.188.207.223 Sai Ram 123 jjj I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-01 Jane Do heather@sfmic.com Crystal Minnesota United States Jane Do Jane Signed (1) The corporation rejects the employers’ liability coverage. jkl fdaf@gmail.com fdas fdas fads fad afde fads Signed
163 2021-01-20 11:08 Anonymous (not verified) 173.233.46.58 Wasmer Post 241 Department of Iowa dba The American Legion 110 Plymouth St SW, Le Mars, IA 51031 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or 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 Kim Wittmar mrkmjm@yahoo.com Le Mars Plymouth iA Muriel J. MIller Richard P. Miller Signed (1) The corporation rejects the employers’ liability coverage. Gary L. Konz claim_buster@yahoo.com Financial Officer Le Mars Plymouth IA Muriel J. Miller Richard P. Miller Signed
164 2021-01-20 11:11 Anonymous (not verified) 173.233.46.58 Wasmer Post 241, Department of Iowa dba The American Legion 110 Plymouth St SW, Le Mars, IA 51031 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or 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 Andrew M. Schultze mrkmjm@yahoo.com Le Mars Plymouth IA Muriel J. Miller Richard P. Miller Signed (1) The corporation rejects the employers’ liability coverage. Gary L. Konz claim_buster@yahoo.com Financial Officer Le Mars Plymouth IA Muriel J. Miller Richard P. Miller Signed
165 2021-01-20 11:14 Anonymous (not verified) 173.233.46.58 Wasmer Post 241, Department of Iowa dba The American Legion 110 Plymouth St SW, Le Mars, IA 51031 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or 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 Matthew Larson mrkmjm@yahoo.com Alton Sioux IA Muriel J. Miller Richard P. Miller Signed (1) The corporation rejects the employers’ liability coverage. Gary L. Konz claim_buster@yahoo.com Financial Officer Le Mars Plymouth IA Muriel J. Miller Richard P. Miller 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
476 2022-05-19 11:45 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 Joseph Holt Joe@kineticsolutons.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 Angey Holt 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
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
224 2021-03-29 11:26 Anonymous (not verified) 174.198.71.64 Pro wash Dubuque inc 1795 Atlantic 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. 2021-03-28 Jordan John block prowashdubuque@gmail.com East Dubuque Jo Davis IL Abigail Ann Metcalf Dawn Marie block Signed (1) The corporation rejects the employers’ liability coverage. Ludovissy insurance jeff@ludovissyandassociates.com He is my agent Dubuque Dubuque country IA Jordan John block Abigail Ann Metcalf 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
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
643 2023-03-30 09:58 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. 2023-03-30 Emily Wallace emily.wallace@spinemoving.com Des Moines Polk Iowa John Wallace Ashley Koch Signed (1) The corporation rejects the employers’ liability coverage. Ashley Koch ashley.koch@spinemoving.com Human Resources Manager West Des Moines Polk Iowa John Wallace Taylor Roth Signed
772 2023-09-18 12:52 Anonymous (not verified) 94.188.207.224 Wallenburg Trucking LLC 911 8th Street SW I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-09-18 Heath Ryan Wallenburg heathwallenburg@gmail.com Rock Valley IA United States Dustin Van Beek Lucas Van Engen Signed (1) The corporation rejects the employers’ liability coverage. Deric Hill d.hill@joemorten.com Insurance Sioux City NE Dakota County Nebraska Dustin Van Beek Lucas Van Engen Signed
275 2021-06-15 13:23 Anonymous (not verified) 172.98.131.84 JAVIER CONSTRUCTION INC 2503 Canyon St SW Cedar Rapids, IA 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-06-15 Javier Adana Javierconstruction88@gmail.com CEDAR RAPIDS LINN IOWA JASON SCHICK LADONNA SCHICK Signed (2) The corporation declines to reject the employers’ liability coverage. JASON SCHICK JASONSCHICK@NEIGHBORINSURANCE.COM INSURANCE AGENT CEDAR RAPIDS LINN IOWA JASON SCHICK LADONNA SCHICK Signed
325 2021-09-03 12:50 Anonymous (not verified) 173.19.58.159 Oskaloosa Entertainment Inc. 507 High Ave W Oskaloosa, IA 52577 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-11 Minesh Patel djraj007@gmail.com Oskaloosa Mahaska Iowa Joe Mauro Randy Mauro Signed (2) The corporation declines to reject the employers’ liability coverage. Joe Mauro joe@mauroinsurance.net insurance agent DES MOINES Polk Iowa Joe Mauro Randy Mauro Signed
326 2021-09-03 12:56 Anonymous (not verified) 173.19.58.159 Oskaloosa Entertainment Inc. 507 High Ave W Oskaloosa, IA 52577 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-11 Rajan Devan djraj007@gmail.com West Des Moines Polk Iowa Joe Mauro Randy Mauro Signed (2) The corporation declines to reject the employers’ liability coverage. Joe Mauro joe@mauroinsurance.net insurance agent DES MOINES Polk United States Joe Mauro Randy Mauro Signed
349 2021-10-22 11:08 Anonymous (not verified) 63.152.48.235 Strong Rock and Gravel LLC 721 S Front St, Lansing, IA 52151 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-04 Ronald Strong stronggravel@gmail.com Llansing Allamakee Iowa James H Bieber Jane Tepesch Signed (1) The corporation rejects the employers’ liability coverage. James H Bieber biebinre@qwestoffice.net Insurance Agent WAUKON Allamakee Iowa James H Bieber Jane Tepesch Signed
449 2022-04-19 21:09 Anonymous (not verified) 172.86.44.178 Holtkamp Transportation LLC 2282 Windmill Way, West Point, IA 52656 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-19 Les Holtkamp les@holtkamplogistics.com West Point Lee Iowa Ben Hogan Tina Holtkamp Signed (2) The corporation declines to reject the employers’ liability coverage. Ben Hogan ben@truserveins.com Insurance Agent Readlyn Bremer Iowa Jaci Hogan Nicole Barnes Signed
570 2022-11-16 10:35 Anonymous (not verified) 50.81.253.108 XU's Golden Dragon 508 Chestnut St., Atlantic, IA 50022 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-16 Xu Long 125529647@QQ.COM Atlantic Cass IA Richard Crall Shannon Crall Signed (1) The corporation rejects the employers’ liability coverage. Richard Crall richard@partnersins.com Insurance Agent Atlantic Cass United States Shannon Crall Richard Crall Signed
571 2022-11-16 10:40 Anonymous (not verified) 50.81.253.108 XU's Golden Dragon 508 Chestnut St., Atlantic, IA 50022 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-16 Tingjie Huang 125529647@QQ.COM Atlantic Cass IA Richard Crall Shannon Crall Signed (1) The corporation rejects the employers’ liability coverage. Richard Crall richard@partnersins.com Insurance Agent Atlantic Cass United States Shannon Crall Richard Crall Signed
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
831 2023-12-06 17:04 Anonymous (not verified) 94.188.205.167 PHOENIX CONSTRUCTION LLC 2219 E 13th St Des Moines, IA 50316 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-02 JUAN PABLO GUTIERREZ LEON jpgutierrez9000@yahoo.com Des Moines IA IA DAISY VASQUEZ Graciela Rodriguez Signed (1) The corporation rejects the employers’ liability coverage. arturo salgado fortworth@aksinsurance.com insured irving TX TX DAISY VASQUEZ DAISY VASQUEZ Signed
834 2023-12-13 08:35 Anonymous (not verified) 94.188.207.228 PHOENIX CONSTRUCTION LLC 2219 E 13TH ST DES MOINES, IA 50316 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-13 JUAN PABLO GUTIERREZ LEON jpgutierrez9000@yahoo.com DES MOINES IA IA DAISY VASQUEZ GRACIELA RODRIGUEZ Signed (1) The corporation rejects the employers’ liability coverage. ARTURO SALGADO commercial@aksinsurance.com Insured Irving TX TX DAISY VASQUEZ GRACIELA RODRIGUEZ Signed
881 2024-02-05 11:08 Anonymous (not verified) 94.188.205.168 Nxt Level 1186 Capital Dr sw I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2024-02-05 Robert Sanders Sandersrob101300@gnail.com cedar rapids Linn iowa n/a n/a Signed (1) The corporation rejects the employers’ liability coverage. next level nextlevelmoving@gmail.com labor cedar rapids linn iowa n/a n/a Signed
882 2024-02-05 11:18 Anonymous (not verified) 94.188.205.175 next level moving 1186 Capital Dr Sw cedar rapids iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2024-02-05 Robert Sanders sandersrob101300@gmail.con cedar rapids linn iowa phoenix sims n/a Signed (2) The corporation declines to reject the employers’ liability coverage. next level moving tarin.nexlevelmoving@gmail.com labor cedar rapids linn iowa n/a n/a Signed
770 2023-09-14 16:23 Anonymous (not verified) 94.188.205.167 Volt Electric Inc 24 Thompson 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. 2023-09-14 Lucas Beschta voltelectriciowa@gmail.com Palo IA United States Sage Stulz Kolt Stulz-obrien Signed (1) The corporation rejects the employers’ liability coverage. Full Name BRIAN C. EDDY BEddy@robertseddy.com Lawyer for the company Independace buchanan IA sage stulz Kolt stulz-obrien Signed
226 2021-04-01 11:52 Anonymous (not verified) 97.125.87.4 JK Holdings 1300 NW 100TH ST. Suite 3000 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. 2020-04-01 Joey Boyens ekindesmoines@gmail.com Clive Polk Iowa Jenae Halstead Cam Naylor Signed (1) The corporation rejects the employers’ liability coverage. Jenae Halstead ekindesmoines@gmail.com Manager Clive Polk Iowa Joey Boyens Cam Naylor Signed
472 2022-05-13 11:19 Anonymous (not verified) 69.18.19.139 BES, Inc. 1615 E Washington St, Mt Pleasant, IA 52641 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-13 Todd Baldridge todd.baldridge@beswatersolutions.com West Branch Cedar Iowa Nicholas Baldridge Owen Baldridge Signed (1) The corporation rejects the employers’ liability coverage. Randy Seberg randy.seberg@beswatersolutions.com Managing Director Mt Pleasant Henry IA John Rodewald Matt Mowery Signed
771 2023-09-17 13:33 Anonymous (not verified) 94.188.205.176 Apex Landlord Services LLC 429 Shetland Dr 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. 2023-09-17 Benjamin Walhood info@apexlandlordservices.com Cedar Rapids Linn Iowa Justin Goebel Jennifer Goebel Signed (1) The corporation rejects the employers’ liability coverage. Benjamin Walhood info@apexlandlordservices.com Managing Member Cedar Rapids Linn Iowa Justin Goebel Jennifer Goebel Signed
530 2022-09-02 13:17 Anonymous (not verified) 173.20.146.6 Nicci Keck LLC 1107 Pheasant Valley St, 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. 2021-09-02 Nicole Keck niccikeckllc@gmail.com Iowa City Johnson Iowa Evangeline Kadera Denise Kandel Signed (1) The corporation rejects the employers’ liability coverage. Nicole Keck niccikeckllc@gmail.com Managing Member/Owner/President Iowa City Johnson Iowa Evangeline Kadera Denise Kandel Signed
531 2022-09-02 13:19 Anonymous (not verified) 173.20.146.6 Nicci Keck LLC 1107 Pheasant Valley St, 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. 2021-09-02 Benjamin Darbro darbrob@gmail.com Iowa City Johnson Iowa Evangeline Kadera Denise Kandel Signed (1) The corporation rejects the employers’ liability coverage. Nicole Keck niccikeckllc@gmail.com Managing Member/Owner/President Iowa City Johnson Iowa Evangeline Kadera Denise Kandel Signed
70 2020-04-21 10:29 Anonymous (not verified) 173.24.181.211 Mr. Drain Man LLC 607 36th Street, Spirit Lake IA 51360 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-21 Jan Coon jennifer@walkerinsuranceia.com Spirit Lake Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Mr Drain Man LLC jennifer@walkerinsuranceia.com Member Spirit Lake Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
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
579 2022-12-07 14:37 Anonymous (not verified) 96.31.1.206 IGL RENTAL LLC PO BOX 317 ARNOLDS PARK IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-10-25 CHAD JONES STAYBOJI@GMAIL.COM ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The corporation rejects the employers’ liability coverage. CHAD JONES STAYBOJI@GMAIL.COM MEMBER ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
648 2023-04-04 14:43 Anonymous (not verified) 94.188.207.224 IBARRAS CONSTRUCTION LLC 4125 56th St Des Moines IA 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. 2023-04-04 SERAFIN ORENDAIN RIVERA ld.hispanicservicesllc@gmail.com Moines Polk County IA Lizeth Mora Felipe Pardo Signed (1) The corporation rejects the employers’ liability coverage. SERAFIN ORENDAIN RIVERA ld.hispanicservicesllc@gmail.com Member Moines Polk County IA Lizeth Mora Felipe Pardo Signed
780 2023-10-04 16:18 Anonymous (not verified) 94.188.207.228 Premier Staffing Agency 6887 Dakota drive West Desmoines Iowa 50266 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-10 Felistas Kimani mwangifelistas4@gmail.com West Desmoines Dallas Iowa Denis Waweru George Komu Signed (1) The corporation rejects the employers’ liability coverage. Felistas Kimani mwangifelistas4@gmail.com member West Desmoines Dallas Iowa Denis Waweru George Komu Signed
805 2023-10-31 14:53 Anonymous (not verified) 94.188.207.225 PJ Trucking Unlimited LLC 2617 380th Ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-31 Peggy Jensen pegandhalj@gmail.com Farragut Fremont Iowa Julie Marshall Darlene Carpenter Signed (1) The corporation rejects the employers’ liability coverage. Peggy Jensen pegandhalj@gmail.com Member Farragut US US Julie Marshall Darlene Carpenter Signed
811 2023-11-11 11:04 Anonymous (not verified) 94.188.205.175 PJ Trucking Unlimited LLC 2617 380th Ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-11 Peggy Jensen pegandhalj@gmail.com Farragut Fremont IA Darlene Carpenter Julie Marshall Signed (1) The corporation rejects the employers’ liability coverage. Peggy Jensen pegandhalj@gmail.com Member Farragut Fremont IA Darlene Carpenter Julie Marshall Signed
822 2023-11-20 09:43 Anonymous (not verified) 94.188.207.223 Lifeson LLC 303 6th Ave Coralville IA 52241 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-14 Scott Parshall scott@lifeson.com Coralville Johnson Iowa Samantha Mlavsky Pamela Mahon Signed (1) The corporation rejects the employers’ liability coverage. Scott Parshall scott@lifeson.com member Coralville Johnson Iowa Samantha Mlavsky Pamela Mahon Signed
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
900 2024-02-26 11:00 Anonymous (not verified) 94.188.207.226 roorda dairy llc 5128 460th st I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-22 lance roorda lgroorda@gmail.com sioux center sioux county iowa larry roorda scott roorda Signed (1) The corporation rejects the employers’ liability coverage. kyle blankers kyle@veinsurance.com member 5128 460th st obrien county iowa larry roorda scott roorda Signed
901 2024-02-26 11:02 Anonymous (not verified) 94.188.207.227 roorda dairy llc 5128 460th st I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-22 larry roorda lgroorda@gmail.com paullina obrien county iowa lance roorda scott roorda Signed (1) The corporation rejects the employers’ liability coverage. kyle blankers kyle@veinsurance.com member 5128 460th st obrien county iowa lance roorda scott roorda Signed
902 2024-02-26 11:37 Anonymous (not verified) 94.188.207.228 roorda dairy llc 5128 460th st I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-22 scott roorda scottyroorda@hotmail.com granville obrien county iowa lance roorda larry roorda Signed (1) The corporation rejects the employers’ liability coverage. kyle blankers kyle@veinsurance.com member 5128 460th st obrien county iowa lance roorda larry roorda Signed
950 2024-04-08 07:16 Anonymous (not verified) 94.188.207.223 J&J Exteriors 32670 190th st granger Iowa 50109 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-04-08 Joshua w klein jjexteriorsofiowa@gmail.com Granger Dallas Iowa Leah klein Ethan faughn Signed (1) The corporation rejects the employers’ liability coverage. Joshua klein jjexteriorsofiowa@gmail.com Member Granger Dallas Iowa Leah klein Ethan Faughn Signed
974 2024-05-06 08:02 Anonymous (not verified) 94.188.205.176 Milton Recycling & Roll Off Service LLC 1266 218 PL, Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-06 Glenn Kreuder kreuderfarms@yahoo.com Boone IA United States Amanda Krull Adam Krull Signed (1) The corporation rejects the employers’ liability coverage. Glenn Kreuder kreuderfarms@yahoo.com Member Boone IA United States Amanda Krull Adam Krull Signed
991 2024-05-16 11:50 Anonymous (not verified) 94.188.207.229 NSG, LLC 2935 Highway 18, Dickens, IA 51333 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-16 Rosemary G Norgaard rosemary@norgaardllc.com Dickens Clay United States Dan Claus Ange Claus Signed (1) The corporation rejects the employers’ liability coverage. Rosemary G Norgaard rosemary@norgaardllc.com MEMBER Dickens Clay United States Dan Claus Ange Claus Signed
161 2021-01-14 19:19 Anonymous (not verified) 108.174.118.195 Four Seasons HVAC LLC 3165 Four Seasons Drive, Stevensville, MT 59870 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-14 Douglas Michael Ostrenga doug@fourseasonshvac.com Stevensville Ravalli MT Zachery Donald Wiediger Thomas Maximillian Liedtka Signed (1) The corporation rejects the employers’ liability coverage. Julie Ruthanne Ostrenga julie@fourseasonshvac.com Member Manager Stevensville Ravalli MT Zachery Donald Wiediger Thomas Maximillian Liedtka Signed
758 2023-08-29 11:56 Anonymous (not verified) 94.188.207.229 Ellison building and repair 2722 645th moravia IA 52571 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-18 Keeton Ellison keeton2005@gmail.com Moravia Appanoose Iowa Cory Ellison Sammy Ellison Signed (1) The corporation rejects the employers’ liability coverage. Sammy Ellison sammyllsn@yahoo.com Mom Moravia Monroe Iowa Cory Ellison Sammy Ellison Signed
198 2021-03-03 17:14 Anonymous (not verified) 173.29.156.163 Jdw 329 E. 11th st davenport iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-03 James holzer slickninja00@gmail.com Davenport Scott Iowa Alyssa holzer Kory munn Signed (2) The corporation declines to reject the employers’ liability coverage. James holzer slickninja00@gmail.com Myself Davenport Scott Iowa Alyssa holzer Kory munn Signed
693 2023-06-19 15:48 Anonymous (not verified) 94.188.207.224 mike mcfarland 7212 parkwood ln 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. 2023-06-19 michael chad mcfarland mikecmcfarland@gmail.com cedar rapids linn United States Omar M Zepeda jamie mcfarland Signed (1) The corporation rejects the employers’ liability coverage. michael chad mcfarland mikecmcfarland@gmail.com myself cedar rapids linn United States Omar M Zepeda jamie mcfarland Signed
945 2024-04-03 20:00 Anonymous (not verified) 94.188.207.229 Timberview Construction 803 TIMBERVIEW DR I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-04-03 Parker Evans Pcevans28@gmail.com ADEL IA United States jason Evans Tricia Evans Signed (1) The corporation rejects the employers’ liability coverage. Timberview Construction Pcevans28@gmail.com Myself ADEL IA United States Jason Evans Tricia Evans Signed
982 2024-05-10 19:06 Anonymous (not verified) 94.188.207.228 Revella Salon and Spa 509 Second St Ida Grove, IA 51445 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or 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 Bailey Roeder roeder428@gmail.com Ida Grove Ida Iowa Dalton Hemer Fina Roeder Signed (1) The corporation rejects the employers’ liability coverage. Bailey Roeder roeder428@gmail.com Myself Ida Grove Ida Iowa Dalton Hemer Fina Roeder Signed
433 2022-03-27 15:30 Anonymous (not verified) 208.126.206.146 J B Engraving 206 4th street East Newhall , Iowa 52315 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-27 John Lauterwasser engravingjb@gmail.com Newhall Benton Iowa Lisa Jane Meeks Brandon Lauterwasser Signed (1) The corporation rejects the employers’ liability coverage. LC Anderson lbandins@southslope.net N/A Newhall Benton Iowa Lisa Jane Meeks Brandon Lauterwasser Signed
434 2022-03-27 15:30 Anonymous (not verified) 208.126.206.146 J B Engraving 206 4th street East Newhall , Iowa 52315 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-27 John Lauterwasser engravingjb@gmail.com Newhall Benton Iowa Lisa Jane Meeks Brandon Lauterwasser Signed (1) The corporation rejects the employers’ liability coverage. LC Anderson lbandins@southslope.net N/A Newhall Benton Iowa Lisa Jane Meeks Brandon Lauterwasser Signed
552 2022-10-03 11:50 Anonymous (not verified) 173.18.48.197 Rancheros construction LLC 1121 Linn Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-25 Salvador Alvarez rancherosconstruction@outlook.com Waterloo Black hwak Iowa Jose Sergio Signed (1) The corporation rejects the employers’ liability coverage. Salvador Alvarez rancherosconstruction@outlook.com N/a Waterloo Black hawk Iowa Jose Sergio Signed
773 2023-09-20 13:48 Anonymous (not verified) 94.188.207.225 RHYO SIDING AND RESTORATION 1475 Wilson Avenue, Cedar Rapids I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-09-09 FERDIN CASTELLANOS MERINO ferdincastellanos7@gmail.com Cedar Rapids Linn County IOWA FERDIN CASTELLANOS MERINO GLORIA RODRIGUEZ Signed (1) The corporation rejects the employers’ liability coverage. N/A customerservice@biberk.com N/A N/A N/A N/A N/A N/A Signed
781 2023-10-05 08:14 Anonymous (not verified) 94.188.205.167 T&R Drywall LLC 1450 NE 69th Pl Ste 56 Ankeny IA 50021 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-05 Juaquin Lopez Gutierrez special.t.d@hotmail.com Des Moines Polk County Iowa Omar Tippetts Omar Tippetts Jr Signed (1) The corporation rejects the employers’ liability coverage. N/A special.t.d@hotmail.com N/A N/A N/A N/A N/A N/A Signed
797 2023-10-20 07:04 Anonymous (not verified) 94.188.205.175 T&R Drywall LLC 1450 NE 69th Pl Ste 56 Ankeny IA 50021 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-20 Jose Castro special.t.d@hotmail.com Des Moines Polk County Iowa Omar Tippetts Omar Tippetts Jr Signed (1) The corporation rejects the employers’ liability coverage. N/A special.t.d@hotmail.com N/A N/A N/A N/A N/A N/A Signed
819 2023-11-16 14:25 Anonymous (not verified) 94.188.205.167 T&R Drywall LLC 1450 NE 69th Pl Ste 56 Ankeny, IA 50021 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-16 Jorge Marquez Soto Special.t.d@hotmail.com Des Moines Polk IA Omar L Tippetts Omar L Tippetts Jr Signed (1) The corporation rejects the employers’ liability coverage. N/A special.t.d@hotmail.com N/A N/A N/A N/A N/A N/A Signed
820 2023-11-16 14:32 Anonymous (not verified) 94.188.205.175 T&R Drywall LLC 1450 NE 69th Pl Ste 56 Ankeny, IA 50021 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-01 Jonathan Manzano Special.t.d@hotmail.com Des Moines Polk IA Omar L Tippetts Omar L Tippetts Jr Signed (1) The corporation rejects the employers’ liability coverage. N/A special.t.d@hotmail.com N/A N/A N/A N/A N/A N/A Signed
827 2023-11-22 10:30 Anonymous (not verified) 94.188.205.169 T&R Drywall LLC 1450 NE 69th Pl Ste 56 Ankeny, IA 50021 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-22 Roberto Javier Rodriguez Perez Special.t.d@hotmail.com Waukee Dallas IA Omar L Tippetts Omar L Tippetts Jr Signed (1) The corporation rejects the employers’ liability coverage. N/A special.t.d@hotmail.com N/A N/A N/A N/A N/A N/A Signed
828 2023-11-22 10:39 Anonymous (not verified) 94.188.207.229 T&R Drywall LLC 1450 NE 69th Pl Ste 56 Ankeny, IA 50021 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-22 Julio Cazares Ornelas Special.t.d@hotmail.com Des Moines Polk Iowa Omar L Tippetts Omar L Tippetts Jr Signed (1) The corporation rejects the employers’ liability coverage. N/A special.t.d@hotmail.com N/A N/A N/A N/A N/A N/A Signed
860 2024-01-19 08:59 Anonymous (not verified) 94.188.205.168 T&R Drywall LLC 1450 NE 69th Pl Ste 56 Ankeny, IA 50021 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-19 Carmelo Chavez Special.t.d@hotmail.com Des Moines Polk Iowa Omar L Tippetts Omar L Tippetts Jr Signed (1) The corporation rejects the employers’ liability coverage. N/A special.t.d@hotmail.com N/A N/A N/A N/A N/A N/A Signed
354 2021-11-04 16:26 Anonymous (not verified) 97.64.194.58 D&D Construction 1124 West Donald ST, Waterloo IA 50703 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-11-04 Darrel Caldwell dcaldwell1124@yahoo.com Waterloo Black Hawk County IA Scott Joseph Demuth Catrese Caldwell Signed (1) The corporation rejects the employers’ liability coverage. NA dcaldwell1124@yahoo.com NA NA NA NA NA NA Signed
598 2023-02-10 09:38 Anonymous (not verified) 94.188.207.225 Y & M Cleaning Services Inc. 4380 SE 15th Ct I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-02-10 Martine Martinez martinmtzmartinez@gmail.com Des Moines Polk Iowa Suzanne E Collier Andy Boyd Signed (1) The corporation rejects the employers’ liability coverage. Suzanne E Collier scollie1@amfam.com Non Related Altoona Polk IA Andy Boyd Martin Martinez Signed
124 2020-10-21 14:07 Anonymous (not verified) 173.23.249.165 Madison County Auction Company LLC 1204 West Summit 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. 2020-10-09 Tim Gomez tjagomez@gmail.com Winterset Madison Iowa Sheena Earles Russell Boggs Signed (1) The corporation rejects the employers’ liability coverage. Russell Boggs Russell.Boggs@fbfs.com None St Charles madison iowa Sheena Earles Russell Boggs Signed
138 2020-11-24 14:11 Anonymous (not verified) 173.215.17.41 Dohrmann Enterprises, Inc 2478 260th Ave. DeWitt, Iowa 52742 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-11-24 Joel Dohrmann dohrmannpnh@gmail.com DE WITT Clinton IA Susanne Owen Daron Oberbroecking Signed (1) The corporation rejects the employers’ liability coverage. Susanne Owen sowen@ohnward.com none Camanche Clinton Iowa Joel Dohrmann Daron Oberbroecking Signed
841 2023-12-18 16:28 Anonymous (not verified) 94.188.205.168 Dennis Clement 203 Astor St I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-18 Dennis Clement haight0929@gmail.com Des Moines Polk IA Amanda Thompson Brandi Haight Signed (1) The corporation rejects the employers’ liability coverage. Dennis Clement haight0929@gmail.com none Des Moines polk IA Brandi Haight Amanda Thompson Signed
842 2023-12-18 16:31 Anonymous (not verified) 94.188.205.168 Brandon Clement 3503 South Union St I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-18 Brandon Clement hawthornhill@paramark.us Des Moines Polk IA Brandi Haight Amanda Thompson Signed (1) The corporation rejects the employers’ liability coverage. Brandon Clement hawthornhill@paramark.us none Des Moines polk IA Brandi Haight Amanda Thompson Signed
159 2021-01-12 09:00 Anonymous (not verified) 72.13.20.192 RTA TRUCKING LLC 31504 E Worthington Rd, Worthington, IA 52078 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-01-12 Kirk Pleggenkuhle dba Pleggenkuhle Pride Inc. kirkpleggenkuhle@gmail.com Mingo Jasper IA Rod Jaeger Jennie Jaeger Signed (1) The corporation rejects the employers’ liability coverage. Jennie Jaeger rtatruck@gmail.com office manager Worthington IA United States Rod Jaeger Kirk Pleggenkuhle 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
169 2021-01-26 12:20 Anonymous (not verified) 74.84.91.178 Sunset Ridge Winery LLC 12615 Highway 52 North, Dubuque, 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. 2020-12-07 John Bonnette jbonnette@yahoo.com Dubuque Dubuque Iowa Derrick Parsons Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. John Bonnette jbonnette@yahoo.com Officer Dubuque Dubuque Iowa Derrick Parsons Brenda Lewis Signed
170 2021-01-26 12:23 Anonymous (not verified) 74.84.91.178 Sunset Ridge Winery LLC 12615 Highway 52 North, Dubuque, 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. 2020-12-07 Ann Bonnette jbonnette@yahoo.com Dubuque Dubuque Iowa Derrick Parsons Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. Ann Bonnette jbonnette@yahoo.com Officer Dubuque Dubuque Iowa Derrick Parsons Brenda Lewis Signed
277 2021-06-17 21:34 Anonymous (not verified) 97.125.98.166 J. Bos Holdings 10925 NE 23rd Ave Mitchellville, IA 50169 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-06-17 Jeff Bos jeffbos1967@gmail.com Mitchellville Iowa United States Angela Bos Amy Bos Signed (1) The corporation rejects the employers’ liability coverage. Jeff Bos jeffbos1967@gmail.com officer Mitchellville Iowa United States Angela Bos Amy Bos Signed