345 |
2021-10-11 15:36 |
Anonymous (not verified) |
173.188.10.36 |
Outdoor Pros LLC |
4525 HWY 22 SE |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-11 |
Erik Scott Alberhasky |
erikalberhas@gmail.com |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik Scott Alberhasky |
erikalberhas@gmail.com |
Owner |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
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 |
854 |
2024-01-16 14:59 |
Anonymous (not verified) |
94.188.207.226 |
AJS Sanitation LLC |
504 Locust, St, PO Box 144, Minburn, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-16 |
Jason Mash |
jmash79@yahoo.com |
Minburn |
Dallas |
Iowa |
Don Richardson |
Abbey Luellen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jason Mash |
jmash79@yahoo.com |
President |
Minburn |
Dallas |
Iowa |
Don Richardson |
Abbey Luellen |
Signed |
137 |
2020-11-23 10:11 |
Anonymous (not verified) |
207.32.14.70 |
Community Ambulance Service, Inc. |
15 N 1st St., Estherville, IA 51334 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-11-18 |
Christopher Fuhrman |
christopher.furhrman@edwardjones.com |
Spirit Lake |
Dickinson |
Iowa |
Sara M Fisher |
Abbie J Fuhrman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christopher Fuhrman |
christopher.fuhrman@edwardjones.com |
President |
Spirit Lake |
Dickinson |
Iowa |
Sara M Fisher |
Abbie J Fuhrman |
Signed |
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 |
610 |
2023-02-23 16:19 |
Anonymous (not verified) |
94.188.207.228 |
Glorious tile service llc |
3905 NE 6th st Ankeny IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2023-02-23 |
Heileselaisi unguec |
glorioustile6@gmail.com |
Ankeny |
United States |
IOWA |
Robert duku |
Abraham deng |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Heileselaisi unguec |
glorioustile6@gmail.com |
Owner llc member |
Ankeny |
United States |
Iowa |
Robert duku |
Abraham deng |
Signed |
611 |
2023-02-23 16:27 |
Anonymous (not verified) |
94.188.207.224 |
Sandra unguec |
3905 NE 6th st Ankeny IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2023-02-23 |
Sandra unguec |
glorioustile6@gmail.com |
Ankeny |
United States |
Iowa |
Robert duku |
Abraham deng |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Sandra unguec |
glorioustile6@gmail.com |
Wife of the owner |
Ankeny |
United States |
Iowa |
Robert duku |
Abraham deng |
Signed |
555 |
2022-10-06 17:48 |
Anonymous (not verified) |
67.22.198.94 |
Baker Irrigation inc |
2621 310th st |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-10-08 |
Daniel Brent Baker |
dan@bakerirrigationia.com |
ROCK VALLEY |
IA |
United States |
Adam Kooistra |
Alex De Jager |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Baker |
dan@bakerirrigationia.com |
President |
ROCK VALLEY |
IA |
United States |
Alex DeJager |
Adam Kooistra |
Signed |
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 |
829 |
2023-11-27 08:59 |
Anonymous (not verified) |
94.188.207.224 |
Adam Ruess Masonry |
206.w Elm st |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-27 |
Adam Ruess |
ruess33@gmail.com |
Lone Tree |
IA |
United States |
Adam Ruess |
Adam Ruess |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam Ruess |
ruess33@gmail.com |
Owner |
Lone Tree |
IA |
United States |
Adam Ruess |
Adam Ruess |
Signed |
904 |
2024-02-28 06:52 |
Anonymous (not verified) |
94.188.205.167 |
Monarca General Builders LLC. |
551 Martin Rd Waterloo Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-28 |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
President |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
905 |
2024-02-28 11:47 |
Anonymous (not verified) |
94.188.207.228 |
Monarca General Builders LLC |
551 Martin Rd Waterloo Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-01 |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
Presidente |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
669 |
2023-05-15 09:26 |
Anonymous (not verified) |
94.188.207.229 |
SOUTHWEST IOWA ELECTRIC LLC |
800 NW SPRUCE ST,EARLHAM, IA 50072 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-05-12 |
ISAAC NORTON |
NORTON2412@GMAIL.COM |
EARLHAM |
DALLAS |
IOWA |
GARRETT ROBINSON |
ADDILIE NORTON |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
ISAAC NORTON |
NORTON2412@GMAIL.COM |
PRESIDENT |
EARLHAM |
DALLAS |
IOWA |
GARRETT ROBINSON |
ADDILIE NORTON |
Signed |
858 |
2024-01-18 08:24 |
Anonymous (not verified) |
94.188.207.226 |
Custom Flooring LLC |
7085 Bloomfield Road Lot 249 Des Moines, Iowa 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-18 |
Jesus Vera |
jesusvera199027@icloud.com |
Des Moines |
Polk |
Iowa |
Natalia Vera |
Adriana de Anda |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jesus Vera |
jesusvera199027@icloud.com |
Owner |
Des Moines |
Polk |
Iowa |
Natalia Vera |
Adriana de Anda |
Signed |
456 |
2022-04-29 08:14 |
Anonymous (not verified) |
107.126.24.57 |
Thatcher Auto Center INC |
406 S West Ave. Baxter, IA 50028 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-01 |
Matthew Lee Wells |
Praynostop@msn.com |
Des Moines |
Polk |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rick Thatcher |
rickswrecks@gmail.com |
President |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
457 |
2022-04-29 08:21 |
Anonymous (not verified) |
107.126.24.57 |
Thatcher Auto Center INC |
406 S West ave Baxter, IA 50028 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-01 |
Nathan Doubek |
thatcherautocenter@gmail.com |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rick Thatcher |
rickswrecks@gmail.com |
President |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
458 |
2022-04-29 08:26 |
Anonymous (not verified) |
107.126.24.57 |
Thatcher Auto Center INC |
406 S West ave Baxter Iowa 50028 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-01 |
Richard Thatcher |
rickswrecks@gmail.com |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nathan Doubek |
thatcherautocenter@gmail.com |
Vice President |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
459 |
2022-04-29 08:49 |
Anonymous (not verified) |
107.126.24.57 |
Thatcher Auto Center INC |
406 S West ave Baxter. IA 50028 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-02-15 |
David Kirkman |
kirkcola@gmail.com |
Newton |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rick Thatcher |
rickswrecks@gmail.com |
President |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
492 |
2022-06-06 20:18 |
Anonymous (not verified) |
69.54.109.51 |
R C TRUCKING, LTD. |
16125 310th Street, Mason City, Iowa 50401 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or 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 |
ROGER CHIZEK |
joldoak@gmail.com |
MASON CITY |
Iowa |
United States |
Kathy Zobrist |
Alan Zobrist |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
ROGER CHIZEK |
joldoak@gmail.com |
President |
MASON CITY |
Iowa |
United States |
Kathy Zobrist |
Alan Zobrist |
Signed |
43 |
2020-02-28 09:50 |
Anonymous (not verified) |
173.24.140.77 |
W R Main Contractor Inc |
1620 NW 78th Street, Clive, IA 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-28 |
Cindy Jo Ohmart |
co4mainco@aol.com |
West Des Moines |
Polk |
Iowa |
Jill Ann Reber |
Alane Marguerite Richardson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mark I Main |
markmain@icloud.com |
President |
Waukee |
Dallas |
Iowa |
Jill Ann Reber |
Alane Marguerite Richardson |
Signed |
794 |
2023-10-18 08:21 |
Anonymous (not verified) |
94.188.205.177 |
J&M Tire and Repair |
31006 hedge ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-18 |
Macklin Paul Barkley |
flyingtank92@yahoo.com |
merrill |
Iowa |
United States |
Brandon Norris |
Alex Barkley |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Macklin Paul Barkley |
jmtireandrepair@gmail.com |
Owner |
sioux city |
Iowa |
United States |
Brandon Norris |
Alex Barkley |
Signed |
38 |
2020-02-08 13:16 |
Anonymous (not verified) |
208.126.52.97 |
Savage Industries Inc |
2368 110th street Delmar, ia 52037 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-08 |
Jordan Hicks |
jjjhicks22@gmail.com |
Delmar |
Clinton |
Iowa |
Brittany Hicks |
Alex Laban |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jordan Hicks |
jjjhicks22@gmail.com |
President |
Delmar |
Clinton |
Iowa |
Brittany Hicks |
Alex Laban |
Signed |
252 |
2021-05-04 13:47 |
Anonymous (not verified) |
159.242.43.24 |
J. Fox Distributing, Inc |
3801 Pierce Street, Sioux City, IA 51104 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-04 |
Joseph Fox |
huskerjoe12@gmail.com |
Sioux City |
Woodbury |
IA |
Jenny McIntyre |
Alex Meier |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph Fox |
huskerjoe12@gmail.com |
President |
Sioux City |
Woodbury |
IA |
Jenny McIntyre |
Alex Meier |
Signed |
759 |
2023-08-31 16:11 |
Anonymous (not verified) |
94.188.207.230 |
Living Free Ministries |
11 2nd St NW, Mason City, IA 50401 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-31 |
Jani Dahlin |
livingfreeiowa@gmail.com |
Mason City |
Cerro Gordo |
IA |
Jenny McIntyre |
Alex Meier |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jani Dahlin |
livingfreeiowa@gmail.com |
President |
Mason City |
Cerro Gordo |
IA |
Jenny McIntyre |
Alex Meier |
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 |
783 |
2023-10-06 11:08 |
Anonymous (not verified) |
94.188.207.223 |
Hawkeye Construction and Snow Removal |
3581 Perch Drive SE, Unit C, Iowa City, Iowa 52240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-06 |
Mark Phelps |
maintenance@hawkeyecampus.com |
Iowa City |
Johnson |
Iowa |
Elizabeth Phelps |
Alexandra Phelps |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mark Phelps |
maintenance@hawkeyecampus.com |
owner |
Iowa City |
Johnson |
Iowa |
Elizabeth Phelps |
Alexandra Phelps |
Signed |
737 |
2023-08-10 21:39 |
Anonymous (not verified) |
94.188.207.224 |
fixIT.fyi, LLC |
1243 Buchanan Ave, Sioux City, IA 51108 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-10 |
Daisy Larae Neuroth |
Daisy@fixIT.fyi |
Sioux City |
Woodbury |
Iowa |
Chad Neuroth |
Alice Bruns |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daisy Larae Neuroth |
Daisy@fixIT.fyi |
Owner/Same |
Sioux City |
Woodbury |
Iowa |
Chad Neuroth |
Alice Bruns |
Signed |
346 |
2021-10-14 13:54 |
Anonymous (not verified) |
75.162.50.106 |
Dawn's Daycare & Educational Program |
360 NW Walnut Ave, Earlham, Iowa 50072 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-14 |
Dawn Lynnete Stonehocker |
daycare.dawn@gmail.com |
Earlham |
Madison |
Iowa |
Anne Marie Larson |
Alison Renae Werts |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dawn Lynnette Stonehocker |
daycare.dawn@gmail.com |
Self |
Earlham |
Madison |
Iowa |
Anne Marie Larson |
Alison Renae Werts |
Signed |
347 |
2021-10-14 19:28 |
Anonymous (not verified) |
75.162.50.106 |
Dawn's Daycare |
360 NW Walnut Ave Earlham,Iowa 50072 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-14 |
James J Stonehocker |
j_stonehocker@hotmail.com |
Earlham |
Madison |
iowa |
Anne Larson |
Alison Werts |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James J Stonehocker |
j_stonehocker@hotmail.com |
Owner |
Earlham |
Madison |
Iowa |
Anne Larson |
Alison Werts |
Signed |
923 |
2024-03-19 13:53 |
Anonymous (not verified) |
94.188.207.224 |
Hawki Housing Solutions LLC |
5036 Highway 61 Burlington, Iowa 52601 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-19 |
Kyle Carruthers |
carruthershunters@gmail.com |
Burlington |
Des Moines |
IOWA |
Laura Carruthers |
Allice Smith |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kyle Carruthers |
carruthershunters@gmail.com |
Owner |
Burlington |
Des Moines |
IOWA |
Laura Carruthers |
Allice Smith |
Signed |
20 |
2019-12-30 09:39 |
Anonymous (not verified) |
207.191.194.182 |
LA Trends Addict Inc |
1200 N CENTER POINT RD |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-10-07 |
Laura Frey |
fcrentals1@gmail.com |
HIAWATHA |
Linn |
IA |
Traci Lyons |
Allie DeVore |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Laura Frey |
fcrentals1@gmail.com |
Owner |
HIAWATHA |
Linn |
IA |
Traci Lyons |
Allie DeVore |
Signed |
21 |
2019-12-30 11:28 |
Anonymous (not verified) |
207.191.194.182 |
Bob Stephen Motors Inc |
324 W Main St, Manchester IA 52057 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-11-05 |
Paul Roussell |
twyladetrich@gmail.com |
MANCHESTER |
DELAWARE |
IA |
Traci Lyons |
Allie DeVore |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Heidi Roussell |
twyladetrich@gmail.com |
Vice President |
Manchester |
DELAWARE |
IA |
Traci Lyons |
Allie DeVore |
Signed |
22 |
2019-12-30 11:30 |
Anonymous (not verified) |
207.191.194.182 |
Bob Stephen Motors Inc |
324 West Main St, Manchester IA 52057 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-11-05 |
Heidi Roussell |
twyladetrich@gmail.com |
Manchester |
DELAWARE |
IA |
Traci Lyons |
Allie DeVore |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Roussell |
twyladetrich@gmail.com |
President |
MANCHESTER |
Delaware |
IA |
Traci Lyons |
Allie DeVore |
Signed |
682 |
2023-06-07 16:10 |
Anonymous (not verified) |
94.188.207.223 |
Jake's Insulation Inc. |
2020 Valley High Dr. Cedar Falls, IA |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-07 |
Jacob Ryan Smalley |
jakersmalley@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Emily D Smalley |
Allison L Smalley |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jacob Ryan Smalley |
jakersmalley@gmail.com |
President |
Cedar Falls |
Black Hawk |
Iowa |
Emily Smalley |
Allison Smalley |
Signed |
230 |
2021-04-06 21:15 |
Anonymous (not verified) |
173.23.145.187 |
Jose J Framing |
5301 SE 24th St. Des Moines IA 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2021-01-01 |
Jose J. Castillo |
castillojosejonathan7@gmail.com |
Des Moines |
Polk |
United States |
Perla Landaverde Garcia |
Alma Y. Gaytan |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Jose J. Castillo |
castillojosejonathan7@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Perla Landaverde Garcia |
Alma Y. Gaytan |
Signed |
362 |
2021-11-16 11:20 |
Anonymous (not verified) |
63.227.65.43 |
F&H Aluminum, Inc. |
101 E. Corporate Drive Charles City, Iowa 50616 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-11-16 |
DeWayne Ferch |
fhaluminum@netconx.net |
Kensett |
Worth |
Iowa |
Tom Stephany |
Amanda Korenberg |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
DeWayne Ferch |
fhaluminum@netconx.net |
President |
Kensett |
Worth |
Iowa |
Tom Stephany |
Amanda Korenberg |
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 |
840 |
2023-12-18 16:21 |
Anonymous (not verified) |
94.188.205.166 |
DC Painting Inc |
205 Astor St |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-18 |
Damion Clement |
amanda_thompson_marie@yahoo.com |
Des Moines |
polk |
IA |
Brandi Haight |
Amanda Thompson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Damion Clement |
amanda_thompson_marie@yahoo.com |
owner |
Des Moines |
Polk |
IA |
Brandi Haight |
Amanda Thompson |
Signed |
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 |
418 |
2022-03-03 14:29 |
Anonymous (not verified) |
72.255.79.18 |
Ostafi Communication Inc. |
2121 Swan Dr. Camanche, IA 52730 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-03 |
Eduard Ostafi |
ostaficommunication@gmail.com |
Camanche |
Clinton |
IA |
Stephanie Millage |
Amanda Van Theemsche |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Eduard Ostafi |
ostaficommunication@gmail.com |
President |
Camanche |
Clinton |
IA |
Stephanie Millage |
Amanda Van Theemsche |
Signed |
385 |
2022-01-11 08:27 |
Anonymous (not verified) |
173.29.238.103 |
Brilliant All-Seasons Lighting Inc. |
10357 NW 42nd St., Polk City, IA 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-11 |
Bradley Harold Loney |
bloney@live.com |
Polk City |
Polk |
Iowa |
Linda Delin |
Amanda Warywoda |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Katrina Loney |
katrinaloney@outlook.com |
Vice President |
Polk City |
Polk |
Iowa |
Linda Delin |
Amanda Warywoda |
Signed |
386 |
2022-01-11 08:30 |
Anonymous (not verified) |
173.29.238.103 |
Brilliant All-Seasons Lighting Inc. |
10357 NW 42nd St., Polk City, IA 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2022-01-11 |
Katrina Marie Loney |
katrinaloney@outlook.com |
Polk City |
Polk |
Iowa |
Linda Delin |
Amanda Warywoda |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Brad Loney |
bloney@live.com |
President |
Polk City |
Polk |
Iowa |
Linda Delin |
Amanda Warywoda |
Signed |
270 |
2021-06-01 15:39 |
Anonymous (not verified) |
206.72.14.249 |
TCS Fabricating, Inc |
315 Hwy 22 Keswick, IA 50136 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-21 |
Lisa Sieren |
TCSFAB@NETINS.NET |
Keswick |
Keokuk |
Iowa |
Scott Grimm |
Amber Kephart |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa Sieren |
TCSFAB@NETINS.NET |
President |
Keswick |
Keokuk |
Iowa |
Scott Grimm |
Amber Kephart |
Signed |
271 |
2021-06-01 15:39 |
Anonymous (not verified) |
206.72.14.249 |
TCS Fabricating, Inc |
315 Hwy 22 Keswick, IA 50136 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-21 |
Tom Sieren |
TCSFAB@NETINS.NET |
Keswick |
Keokuk |
Iowa |
Scott Grimm |
Amber Kephart |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tom Sieren |
TCSFAB@NETINS.NET |
Vice President |
Keswick |
Keokuk |
Iowa |
Scott Grimm |
Amber Kephart |
Signed |
281 |
2021-06-30 10:59 |
Anonymous (not verified) |
206.72.14.249 |
TCS Fabricating, Inc |
315 Hwy 22 Keswick, IA 50136 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-06-30 |
Tom Sieren |
TCSFAB@NETINS.NET |
Keswick |
Keokuk |
Iowa |
Scott Grimm |
Amber Kephart |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tom Sieren |
TCSFAB@NETINS.NET |
Vice President |
Keswick |
IA |
United States |
Scott Grimm |
Amber Kephart |
Signed |
179 |
2021-02-16 18:03 |
Anonymous (not verified) |
216.248.123.206 |
Outer Edge Screen Printing |
2449 68th Street Van Horne, Iowa 52346 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-16 |
Kyle Christopher Kline |
outedgekim@gmail.com |
Van Horne |
IA |
United States |
Kelsea Marie Kline |
Amber Marie Valentine |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kimberly Sue Kline |
outedgekim@gmail.com |
spouse |
Van Horne |
IA |
United States |
Kelsea Marie Kline |
Amber Lynn Valentine |
Signed |
635 |
2023-03-23 15:43 |
Anonymous (not verified) |
94.188.207.228 |
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 |
Kevin Babb |
kbabb@viahealthservices.com |
Waukee |
Dallas |
Iowa |
Jackie Hastings |
Amber Perdue |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jennifer Conner |
jconner@viahealthservices.com |
President |
Des Moines |
Polk |
IA |
Jackie Hastings |
Amber Perdue |
Signed |
636 |
2023-03-23 15:49 |
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 |
Robert Conner |
dr.conner@metrogeriatrics.com |
Norwalk |
Warren |
Iowa |
Jackie Hastings |
Amber Perdue |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jennifer Conner |
jconner@viahealthservices.com |
President |
Des Moines |
Polk |
IA |
Jackie Hastings |
Amber Perdue |
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 |
199 |
2021-03-03 17:32 |
Anonymous (not verified) |
172.58.86.222 |
Mike Underdahl |
1536 W Locust St |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-03 |
Mike Underdahl |
mwunderdahl1974@gmail.com |
Davenport |
Scott |
Iowa |
Phillip Gerald Hoxsey |
Amee Ann Pepperson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Wayne Underdahl |
mwunderdahl1974@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Phillip Gerald Hoxsey |
Amme Ann Pepperson |
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 |
176 |
2021-02-03 15:02 |
Anonymous (not verified) |
174.198.90.166 |
Jesse's Embers LLC |
3301 Ingersoll Ave, Des Moines, IA, 50312 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-03 |
Deena Edelstein |
dledelstein@hotmail.com |
Des Moines |
Polk |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Deena Edelstein |
dledelstein@hotmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
177 |
2021-02-03 15:07 |
Anonymous (not verified) |
174.198.90.166 |
Jesse's Embers LLC |
3301 Ingersoll Ave, Des Moines, IA, 50312 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-03 |
Martin Scarpino |
martyscarpino@yahoo.com |
Des Moines |
Polk |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Martin Scarpino |
martyscarpino@yahoo.com |
Owner |
Des Moines |
IA |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
152 |
2021-01-04 12:08 |
Anonymous (not verified) |
104.129.206.120 |
Schleswig Transfer Inc |
216 Valley View Dr, Schleswig, IA 51461 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-11-30 |
Wade Miller |
t.uhl3@joemorten.com |
Schleswig |
Crawford |
Iowa |
Tamara Uhl |
Amy Meseck |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Wade Miller |
t.uhl3@joemorten.com |
President |
Schleswig |
Crawford |
IA |
Tamara Uhl |
Amy Meseck |
Signed |
426 |
2022-03-22 12:06 |
Anonymous (not verified) |
69.54.105.130 |
Downing Development, Ltd. |
13004 NW 44th St Polk City, IA 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-22 |
Carolyn Suzanne Downing |
susiedowningdevelopment@gmail.com |
Polk City |
IA |
United States |
Geneva Aki Ross |
Amy Sue Romero |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Carolyn Suzanne Downing |
susiedowningdevelopment@gmail.com |
Secretary |
Polk City |
Polk County |
Iowa |
Geneva Aki Ross |
Amy Sue Romero |
Signed |
427 |
2022-03-22 12:08 |
Anonymous (not verified) |
69.54.105.130 |
Downing Development, Ltd. |
13004 NW 44th St Polk City, IA 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-22 |
Steven Jeffrey Downing |
stevedowningdevelopment@gmail.com |
Polk City |
Polk County |
Iowa |
Geneva Aki Ross |
Amy Sue Romero |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Steven Jeffrey Downing |
stevedowningdevelopment@gmail.com |
President |
Polk City |
Polk County |
Iowa |
Geneva Aki Ross |
Amy Sue Romero |
Signed |
685 |
2023-06-15 12:30 |
Anonymous (not verified) |
94.188.205.168 |
Des Moines Marble & Mantel Co. Inc. |
1507 Ohio Street Des Moines, IA 50314 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-15 |
Benjamin Campos Rojas |
caya05rojas@gmail.com |
Des Moines |
Polk county |
Iowa |
Erica Antonio Maya |
Ana Antonio Maya |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mario DeMarco |
sandyatdmmarble@aol.com |
Owner |
Des Moines |
Polk County |
Iowa |
Erica Antonio Maya |
Ana Antonio Maya |
Signed |
687 |
2023-06-16 07:59 |
Anonymous (not verified) |
94.188.207.230 |
Benjamin Campos Rojas |
4024 52nd Street Des Moines, Iowa 50310 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-16 |
Benjamin Campos Rojas |
caya05rojas@gmail.com |
Des Moines |
Polk |
Iowa |
Erica Antonio Maya |
Ana Antonio Maya |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Benjamin Campos Rojas |
caya05rojas@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Erica Antonio Maya |
Ana Antonio Maya |
Signed |
731 |
2023-08-04 09:43 |
Anonymous (not verified) |
94.188.207.229 |
Hopp's Computers & More |
855 S. Page St., Nauvoo, IL 62354 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-04 |
James Hopp |
tech@hoppcomputers.com |
Nauvoo |
Hancock |
Illinois |
Carol McGhghy |
Ana LeVesque |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Hopp |
tech@hoppcomputers.com |
Owner |
Nauvoo |
Hancock |
Illinois |
Carol McGhghy |
Ana LeVesque |
Signed |
857 |
2024-01-17 16:04 |
Anonymous (not verified) |
94.188.205.167 |
GA Drywall LLC |
1906 West State Street Marshalltown Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-17 |
Oscar Vazquez LOPEZ |
gadrywall7@icloud.com |
Marshalltown |
Marshall |
Iowa |
Ana Ibarra |
Ana Lopez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Oscar Vazquez Lopez |
oscarlopez177@icloud.com |
Owner |
Marshalltown |
Marshall |
Iowa |
Ana Ibarra |
Ana Lopez |
Signed |
876 |
2024-01-30 17:55 |
Anonymous (not verified) |
94.188.207.230 |
Erik Mortens |
9823 nw 46th ct polk city iowa 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-30 |
Erik mortens |
Erik.mortens@gmail.com |
Polk city |
Polk |
Iowa |
Andrea Davis |
Kali Davis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik mortens |
Erik.mortens@gmail.com |
Self |
Polk city |
Polk |
Iowa |
Kali Davis |
Andrea Davis |
Signed |
877 |
2024-01-30 17:58 |
Anonymous (not verified) |
94.188.207.230 |
Erik Mortens |
9823 nw 46th ct polk city iowa 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-30 |
Steffanie Mortens |
steffanie.mortens@gmail.com |
Polk city |
Polk |
Iowa |
Andrea Davis |
Kali Davis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik mortens |
Erik.mortens@gmail.com |
Self |
Polk city |
Polk |
Iowa |
Kali Davis |
Andrea Davis |
Signed |
420 |
2022-03-04 13:58 |
Anonymous (not verified) |
209.180.36.109 |
Sani Enterprise LLC |
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. |
2022-03-04 |
Mustafa Keserovic |
MustafaKeserovic@gmail.com |
Ankeny |
Pokl |
Iowa |
Sandro Tadic |
Andrew Swanson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sandro Tadic |
sanienterprise14@gmail.com |
Owner |
WEST DES MOINES |
Iowa |
United States |
Sandro Tadic |
Andrew swanson |
Signed |
503 |
2022-06-30 17:15 |
Anonymous (not verified) |
209.180.36.109 |
Sani Enterprise |
101 Ashworth Rd |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-30 |
Nexhat Krasniqi |
nexhat_80@hotmail.com |
WEST DES MOINES |
polk |
Iowa |
Sandro Tadic |
Andy Swanson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sandro Tadic |
sanienterprise14@gmail.com |
Owner |
Urbandale |
Polk |
Iowa |
Sandro Tadic |
Andy Swanson |
Signed |
504 |
2022-06-30 17:18 |
Anonymous (not verified) |
209.180.36.109 |
Sani Enterprise |
101 Ashworth Rd |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-30 |
Timothy Roberts |
roberts.timoty2@gmail.com |
Des Moines |
Polk |
Iowa |
Sandro Tadic |
Andy Swanson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sandro Tadic |
sanienterprise14@gmail.com |
Owner |
Urbandale |
polk |
iowa |
Sandro Tadic |
Andy Swanson |
Signed |
505 |
2022-06-30 17:20 |
Anonymous (not verified) |
209.180.36.109 |
Sani Enterprise |
101 Ashworth Rd |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-30 |
Admir Dogic |
adoydogic@gmail.com |
Urbandale |
polk |
iowa |
Sandro Tadic |
Andy Swanson |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Sandro Tadic |
sanienterprise14@gmail.com |
Owner |
Urbandale |
polk |
iowa |
Sandro Tadic |
Andy Swanson |
Signed |
506 |
2022-06-30 17:23 |
Anonymous (not verified) |
209.180.36.109 |
Sani Enterprise |
101 Ashworth Rd |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-30 |
Nada Krasniqi |
najstor406@gmail.com |
Johnston |
Polk |
iowa |
Sandro Tadic |
Andy Swanson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sandro Tadic |
sanienterprise14@gmail.com |
Owner |
Urbandale |
polk |
iowa |
sandro tadic |
andy swanson |
Signed |
507 |
2022-06-30 17:25 |
Anonymous (not verified) |
209.180.36.109 |
Sani Enterprise |
101 Ashworth Rd |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-30 |
Julia hernandez |
juliaherdz.1983@gmail.com |
Des Moines |
polk |
iowa |
Sandro Tadic |
Andy Swanson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sandro Tadic |
sanienterprise14@gmail.com |
Owner |
Urbandale |
polk |
iowa |
sandro tadic |
andy swanson |
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 |
339 |
2021-09-29 16:59 |
Anonymous (not verified) |
69.57.16.37 |
MC5 CONSTRUCTION INC |
1186 TEXAS AVE, LU VERNE, IOWA 50560 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-18 |
JOSEPH MCDERMOTT |
joe.mc5construction@gmail.com |
LU VERNE |
HUMBOLDT |
IOWA |
NICHOLAS GARMAN |
ANGELA GARMAN |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
JOSEPH MCDERMOTT |
joe.mc5construction@gmail.com |
OWNER |
LU VERNE |
HUMBOLDT |
IOWA |
NICHOLAS GARMAN |
ANGELA GARMAN |
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 |
410 |
2022-02-20 19:10 |
Anonymous (not verified) |
173.27.233.68 |
A and W marble and tile Inc |
207 Philip St. Des Moines, Iowa 50315 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-02-20 |
Wayne Yergy |
wyergy@gmail.com |
Des Moines |
Polk |
Iowa |
John Noga |
Angie Carter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Wayne A Yergy |
wyergy@gmail.com |
Vice President |
Des Moines |
IA |
United States |
John Noga |
Angie Carter |
Signed |
551 |
2022-10-02 10:56 |
Anonymous (not verified) |
174.198.70.237 |
Des Moines Roofing Contractor |
2234 Highland St Des Moines, IA |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-10-02 |
Nancy Lopez |
nanoran3@gmail.com |
Des Moines |
Polk City |
IA |
Noe Ordaz |
Angie Florian |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nancy Lopez |
nanoran3@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Noe Ordaz |
Angie Florian |
Signed |
880 |
2024-02-04 18:45 |
Anonymous (not verified) |
94.188.205.176 |
One Call Exteriors |
1928 9th St Des Moines IA 50314 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-04 |
Nancy López |
onecallexteriors@gmail.com |
Des Moines |
Polk |
IA |
Noé Ordaz |
Angie Florian |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nancy López |
onecallexteriors@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Noé Ordaz |
Angie Florian |
Signed |
927 |
2024-03-20 23:27 |
Anonymous (not verified) |
94.188.205.177 |
RRB, LLC |
4444 1st Ave NE Ste 510 Cedar Rapids, IA 52402 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-20 |
Kelli Holton |
kelli@rebelroseboutique.co |
Coralville |
IA |
United States |
Dave Booth |
Ann Holton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kelli Holton |
kelli@rebelroseboutique.co |
Owner |
Coralville |
IA |
United States |
Dave Booth |
Ann Holton |
Signed |
641 |
2023-03-29 08:15 |
Anonymous (not verified) |
94.188.205.175 |
THERMOGRAPHIC Wellness |
1000 N. West St, Suite 1200, Wilmington, DE 19801 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-29 |
Palmer Piana |
pianapal@gmail.com |
Davenport |
Scott County |
Iowa |
Olivia Piana |
Anthony Piana |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Olivia Piana |
joinbti@gmail.com |
VP of Operations |
Davenport |
Scott county |
IA |
Palmer Piana |
Anthony Piana |
Signed |
863 |
2024-01-23 13:59 |
Anonymous (not verified) |
94.188.205.176 |
United Marble & Tile, Inc. |
915 8th Street, #201, Boone, IA. 50036 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-24 |
Albert James Gotta |
jim@umtile.com |
Slater |
Boone |
IA |
Antonina M Gotta |
MARY KATE RUSSELL |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Albert James Gotta |
jim@umtile.com |
President Sole Share Holder |
Boone |
IA |
IA |
Antonina M Gotta |
Antonina M Gotta |
Signed |
607 |
2023-02-20 21:53 |
Anonymous (not verified) |
94.188.207.223 |
Rancheros construction LLC |
1121 Linn Street Waterloo Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-09-15 |
Salvador Alvarez |
rancherosconstruction@outlook.com |
Waterloo |
Black hawk |
Iowa |
Adan |
Antonio |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Salvador Alvarez |
rancherosconstruction@outlook.com |
Owner |
Waterloo |
Black hawk |
Iowa |
Adan |
Antonio |
Signed |
568 |
2022-11-15 08:23 |
Anonymous (not verified) |
174.215.243.6 |
Cesar rolando Acosta rivera |
2080 king ave apt 21 Des Moines ia 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-11-15 |
Cesar rolando Acosta Rivera |
acostariveracesarrolando@gmail.com |
Des Moines Iowa |
Polk |
Iowa |
Juan acosta |
Antonio acosta |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cesar rolando Acosta Rivera |
acostariveracesarrolando@gmail.com |
Owner |
Des moines |
Polk |
Iowa |
Juan acosta |
Antonio acosta |
Signed |
569 |
2022-11-15 08:23 |
Anonymous (not verified) |
174.215.243.6 |
Cesar rolando Acosta rivera |
2080 king ave apt 21 Des Moines ia 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-11-15 |
Cesar rolando Acosta Rivera |
acostariveracesarrolando@gmail.com |
Des Moines Iowa |
Polk |
Iowa |
Juan acosta |
Antonio acosta |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cesar rolando Acosta Rivera |
acostariveracesarrolando@gmail.com |
Owner |
Des moines |
Polk |
Iowa |
Juan acosta |
Antonio acosta |
Signed |
992 |
2024-05-17 09:04 |
Anonymous (not verified) |
94.188.207.226 |
DEV Mart Inc |
229 West St Grinnell IA |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-17 |
Rakesh Chaudhari |
grinnellmart@gmail.com |
Muscatine |
Muscatine |
Iowa |
Sam Chaudhari |
Arvind Chaudhari |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rakesh Chaudhari |
grinnellmart@gmail.com |
Owner |
Muscatnine |
Iowa |
Iowa |
Sam Chaudhari |
Arvind Chaudhari |
Signed |
560 |
2022-10-28 16:42 |
Anonymous (not verified) |
207.177.1.151 |
CAC Tent LLC |
2335 300th 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. |
2022-10-28 |
Cory Allen Caldwell |
northiowatentandawning@gmail.com |
Ventura |
Hancock |
Iowa |
Chuck Forrest |
Ashley Kinnan |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cory Caldwell |
northiowatentandawning@gmail.com |
Owner |
Ventura |
Hancock |
Iowa |
Chuck Forrest |
Ashley Kinnan |
Signed |
210 |
2021-03-22 15:20 |
Anonymous (not verified) |
204.155.61.217 |
Agspire Inc |
1310 Kathryn Ct Buffalo, MN 55313 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-05 |
Kent Fiebelkorn |
kent@hailmayday.com |
Buffalo |
Wright County |
Minnesota |
DocuSign |
Ashley Kraft |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kent Fiebelkorn |
kent@hailmayday.com |
Owner |
Buffalo |
Wright County |
Minnesota |
DocuSign |
Ashley Kraft |
Signed |
211 |
2021-03-25 09:10 |
Anonymous (not verified) |
204.155.61.217 |
The New Leaf Co |
1095 Oakdale Ave, St Paul, MN 55118 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-02 |
Michael Hernandaz |
liveabovethecloudz@gmail.com |
St Paul |
Dakota |
MN |
DocuSign |
Ashley Kraft |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Hernandaz |
liveabovethecloudz@gmail.com |
Ower |
St Paul |
Dakota |
mn |
DocuSign |
Ashley Kraft |
Signed |
212 |
2021-03-25 09:26 |
Anonymous (not verified) |
204.155.61.217 |
Mark Burger |
3993 Shoreline Dr, Robbinsdale, MN 55422 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or 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 |
Mark Burger |
markb@hailmayday.com |
Robbinsdale |
hennepin |
MN |
DocuSign |
Ashley Kraft |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mark Burger |
markb@hailmayday.com |
Owner |
Robbinsdale |
Robbinsdale |
MN |
DocuSign |
Ashley Kraft |
Signed |
348 |
2021-10-20 11:06 |
Anonymous (not verified) |
97.116.100.220 |
Gonzalo construction LLC |
5517 Brookdale Dr n apt 105 Brooklyn Park, mn 55443 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-20 |
Gonzalo Roman robles |
gonzaloconstructionmn@gmail.com |
Brooklyn park |
Hennepin |
Minnesora |
Gonzalo Roman robles |
Ashley Kraft |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gonzalo Roman robles |
gonzaloconstruction@gmail.com |
Owner |
Brooklyn park |
Hennepin |
Minnesota |
Gonzalo Roman robles |
Ashley Kraft |
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 |
604 |
2023-02-16 16:13 |
Anonymous (not verified) |
94.188.207.226 |
Transcend Mind Body Wellness and Floatation Clinic |
409 Washington Street, Cedar Falls, IA 50613 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-01 |
Brady Huls |
brady.huls@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Morgan Huls |
Ashlyn Henry |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Morgan Huls |
transcendcedarfalls@gmail.com |
Owner |
Cedar Falls |
Black Hawk |
Iowa |
Brady Huls |
Ashlyn Henry |
Signed |
525 |
2022-08-11 19:30 |
Anonymous (not verified) |
216.51.251.59 |
Ethan pliner trucking |
2510 Kansas ave fort dodge 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. |
2022-08-11 |
Ethan William pliner |
pliner15@hotmail.com |
Fort dodge iowa |
Webster |
Iowa |
Trey Kent Lawrence |
Aubrey Mae Holtorf |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ethan pliner |
pliner15@hotmail.com |
Owner |
Fort Dodge |
Webster |
Iowa |
Trey Kent Lawrence |
Aubrey Mae Holtorf |
Signed |
213 |
2021-03-25 15:45 |
Anonymous (not verified) |
173.20.159.129 |
Goldsmith Ventures, Inc. |
308 E. Burlington St. #183 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-25 |
Jonathan Goldsmith |
jbg789@gmail.com |
Hills |
Johnson |
Iowa |
Monica Goldsmith |
Aura Rodriguez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jonathan Goldsmith |
jbg789@gmail.com |
Owner |
Hills |
Johnson |
Iowa |
Monica Goldsmith |
Aura Rodriguez |
Signed |
537 |
2022-09-20 09:01 |
Anonymous (not verified) |
173.20.206.50 |
Accent Painting LLC |
613 Locust ST |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-09-20 |
Anthony Gilbert Gasco |
accentpainting@yahoo.com |
La Porte City |
Blackhawk |
Iowa |
Arthur Rudolf Gasco |
Aurora Jealee Gasco |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Anthony Gilbert Gasco |
accentpainting@yahoo.com |
Owner |
La Porte City |
Blackhawk |
Iowa |
Arthur Rudolf Gasco |
Aurora Jealee Gasco |
Signed |
955 |
2024-04-11 10:31 |
Anonymous (not verified) |
94.188.207.228 |
Calvillo & Son Construction |
1802 mondamin ave Des Moines Iowa 50314 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-11 |
Gerardo Calvillo |
joedhsanchez@icloud.com |
Des Moines |
Polk |
Iowa |
Agustín Téllez |
Aurora Maciel Colin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gerardo Calvillo |
joedhsanchez@icloud.com |
Owner |
Des Moines |
Polk |
Iowa |
Agustín Téllez |
Aurora Maciel Colin |
Signed |
957 |
2024-04-15 10:15 |
Anonymous (not verified) |
94.188.207.226 |
Calvillo & Son Construction |
1802 Mondamin Ave, Des Moines, Iowa, 50314 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2024-04-15 |
Gerardo Calvillo |
Joedhsanchez@icloud.com |
Des Moines |
Polk |
Iowa |
Agustín Téllez |
Aurora Maciel Colin |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Gerardo Calvillo |
Joedhsanchez@icloud.com |
Owner |
Des Moines |
Polk |
Iowa |
Agustín Téllez |
Aurora Maciel Colin |
Signed |
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 |
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 |
784 |
2023-10-09 13:09 |
Anonymous (not verified) |
94.188.205.177 |
SEHIC G&S LLC |
4201 62nd st apt 4 Urbandale Iowa 50322 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-09 |
Bajro Sehic |
kalesija20@gmail.com |
Urbandale |
Polk |
Iowa |
Bajro sehic |
Bajro sehic |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bajro sehic |
kalesija20@gmail.com |
Owner |
Urbandale |
Polk |
Iowa |
Bajro sehic |
Bajro Sehic |
Signed |
608 |
2023-02-22 16:15 |
Anonymous (not verified) |
94.188.207.225 |
Unity Global Inc |
1779 Shooting Star Ave, Fairfield, IA 52556 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-04 |
Hagen Rainbow |
unityglobalinc@protonmail.com |
Fairfield |
Jefferson |
Iowa |
Peter Defreitas |
Barbara Rainbow |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Hagen Rainbow |
unityglobalinc@protonmail.com |
President |
Fairfield |
Jefferson |
Iowa |
Peter Defreitas |
Barbara Rainbow |
Signed |
40 |
2020-02-14 09:22 |
Anonymous (not verified) |
50.83.38.221 |
Pa's Construction LLC |
2350 Glass RD NE |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-14 |
Daniel Saunders |
dan2112411@yahoo.com |
Cedar Rapids |
USA_IA |
USA_IA |
Walt Cheney |
Becky Cheney |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Saunders |
dan2112411@yahoo.com |
Owner- Manager |
Cedar Rapids |
USA_IA |
USA_IA |
Walt Cheney |
Becky Cheney |
Signed |
708 |
2023-07-14 09:24 |
Anonymous (not verified) |
94.188.205.166 |
Ellis Flying Service Inc. |
6550 HWY 17 South Newport AR 72112 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-07-14 |
Mark Ellis |
fly@ellisflying.com |
Newport |
Arkansas |
United States |
Alex Webb |
Becky Ellis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mark A Ellis |
fly@ellisflying.com |
President |
Newport |
Arkansas |
United States |
Alex Webb |
Becky Ellis |
Signed |
431 |
2022-03-25 15:47 |
Anonymous (not verified) |
199.241.229.222 |
Ney Trucking Inc |
5070 Wolff Rd 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. |
2022-03-25 |
Maria A Ney |
maria@neytrucking.com |
Peosta |
Dubuque |
IA |
Brenda Weatherwax |
Becky Schmelzer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Maria Ney |
maria@neytrucking.com |
President |
Peosta |
Dubuque |
IA |
Brenda Weatherwax |
Becky Schmelzer |
Signed |
432 |
2022-03-25 15:49 |
Anonymous (not verified) |
199.241.229.222 |
Ney Trucking Inc |
5070 Wolff Rd 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. |
2022-03-25 |
Marvin L Ney |
marvin@paramountems.com |
Peosta |
Dubuque |
IA |
Brenda Weatherwax |
Becky Schmelzer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Maria Ney |
maria@neytrucking.com |
President |
Peosta |
Dubuque |
IA |
Brenda Weatherwax |
Becky Schmelzer |
Signed |
903 |
2024-02-27 13:54 |
Anonymous (not verified) |
94.188.205.166 |
MELTZ'S CONSTRUCTION LLC |
402 Jennifer Ln NE Cedar Rapids IA 52402 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-27 |
RICARDO MELTZ |
waymakeranasolorzano@gmail.com |
CADAR RAPIDS |
IA |
United States |
Lysandra Betancourt |
Belkis S Diaz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
ALAN SALGADO |
alan@prime-agents.com |
OWNER |
IRVING |
TX |
United States |
Lysandra Betancourt |
Belkis S Diaz |
Signed |
45 |
2020-03-10 10:24 |
Anonymous (not verified) |
204.141.214.180 |
Shamrock Screenprinting Inc |
2710 Granite Ct NE |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-03-10 |
Lori Handley |
lori.handley@aol.com |
Cedar Rapids |
Linn |
IA |
David Handley |
Beth Barta |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lori Handley |
lori.handley@aol.com |
VP |
Cedar Rapids |
Linn |
IA |
David Handley |
Beth Barta |
Signed |
46 |
2020-03-10 10:26 |
Anonymous (not verified) |
204.141.214.180 |
Shamrock Screenprinting Inc |
2710 Granite Ct NE |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-03-10 |
David Handley |
davehandley53@gmail.com |
Cedar Rapids |
Linn |
IA |
Lori Handley |
Beth Barta |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lori Handley |
Lori.handley@aol.com |
VP |
Cedar Rapids |
Linn |
IA |
Lori Handley |
Beth Barta |
Signed |
373 |
2021-12-10 14:49 |
Anonymous (not verified) |
173.29.69.100 |
CARSTENS FLOOR COVERINGS LLC |
19276 250TH STREET ELDRIDGE, IA 52748 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-12-10 |
MATHEW CARSTENS |
MCARSTENS@NETINS.NET |
ELDRIDGE |
SCOTT |
IA |
TONY BURKHART |
BETH LEMONS |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
MATTHEW CARSTENS |
MCARSTENS@NETINS.NET |
PRESIDENT |
ELDRIDGE |
SCOTT |
IA |
TONY BURKHART |
BETH LEMONS |
Signed |
16 |
2019-12-12 13:17 |
Anonymous (not verified) |
65.126.161.162 |
MGF Concrete DBA Michael Frandsen |
3306 66th Avenue Moline, IL 61265 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-12-12 |
Michael Frandsen |
None@none.com |
Moline |
Rock Island |
Illinois |
Sarah Robertson |
Beth Welzenbach |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Frandsen |
None@none.com |
Owner |
Moline |
Rock Ilsand |
Illinois |
Sarah Robertson |
Beth Welzenbach |
Signed |
17 |
2019-12-12 13:20 |
Anonymous (not verified) |
65.126.161.162 |
Robert J Schroeder Const. Inc. |
10984 150th St Davenport, IA 52804 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-12-12 |
Robert J Schroeder |
None@none.com |
Davenport |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert J Schroeder |
None@none.com |
President |
Davenport |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
23 |
2019-12-31 09:01 |
Anonymous (not verified) |
65.126.161.162 |
Shawn Watson DBA SW Painting |
1205 13th Ave Orion, IL 61273 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-12-31 |
Shawn Michael Watson |
None@none.com |
Orion |
Henry |
Illinois |
Sarah Robertson |
Beth Welzenbach |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Shawn Watson |
None@none.com |
Owner |
Orion |
Henry |
Illinois |
Sarah Robertson |
Beth Welzenbach |
Signed |
47 |
2020-03-10 15:16 |
Anonymous (not verified) |
65.126.161.162 |
Advantage Customer Remodeling LLC |
3236 W 17th Street Davenport, IA 52804 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-03-10 |
Tamethia Mitchell |
None@none.com |
Davenport |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tamethia Mitchell |
None@none.com |
Owner |
Davenport |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
59 |
2020-04-14 12:54 |
Anonymous (not verified) |
65.126.161.162 |
Elite Carpentry |
1515 21st Street Bettendorf, IA 52722 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-10 |
Jeffrey D. Leech |
elitecarpentryqc@gmail.com |
Bettendorf |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Jeffrey D. Leech |
elitecarpentryqc@gmail.com |
President |
Bettendorf |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
69 |
2020-04-21 10:18 |
Anonymous (not verified) |
65.126.161.162 |
Mike Foster DBA Mike's Home Improvement |
2377 W 49th Street Davenport, IA 52806 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-21 |
Michael A Foster Jr. |
None@none.com |
Davenport |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael A Foster Jr. |
None@none.com |
Owner |
Davenport |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
890 |
2024-02-19 12:07 |
Anonymous (not verified) |
94.188.205.174 |
FJ Orisa Construction Inc |
114 Austin Street SW |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-19 |
Jennifer LynnWeirup |
FJOrisaconstruction@yahoo.com |
Cedar Rapids |
Linn |
IA |
Karen Sedlacek |
Billie Jo Moore |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
jennifer lynn weirup |
FJOrisaconstruction@yahoo.com |
self |
Cedar Rapids |
Iowa |
Iowa |
Karen Sedlacek |
Billie Jo Moore |
Signed |
891 |
2024-02-19 12:09 |
Anonymous (not verified) |
94.188.205.169 |
FJ Orisa Construction Inc |
114 Austin Street SW |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-19 |
Felipe Aldana |
FJOrisaconstruction@yahoo.com |
Cedar Rapids |
Linn |
IA |
Karen Sedlacek |
Billie Jo Moore |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Felipe Aldana |
FJOrisaconstruction@yahoo.com |
officer |
Cedar Rapids |
Iowa |
Iowa |
Karen Sedlacek |
Billie Jo Moore |
Signed |
318 |
2021-08-23 11:00 |
Anonymous (not verified) |
216.51.164.69 |
Z Homes and Realty Inc |
1324 3rd Ave SE Sioux Center IA 51250 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-19 |
Beverly Zwart |
mbzwrt@mtcnet.net |
Sioux Center |
Sioux |
IA |
Lisa Dykstra |
Blake Kruger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Beverly Zwart |
mbzwrt@mtcnet.net |
Owner |
Sioux Center |
Sioux |
IA |
Lisa Dykstra |
Blake Kruger |
Signed |
390 |
2022-01-20 11:06 |
Anonymous (not verified) |
162.246.237.102 |
High Pointe Construction |
903 Summerset pl Indianola iowa 50125 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-19 |
Andrey Shabak |
shabakandre@gmail.com |
indianola |
warren |
Iowa |
Inna zayets |
bob |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andrey shabak |
shabakandre@gmail.com |
owner |
indianola |
warren |
ia |
inna zayets |
bob |
Signed |
94 |
2020-07-02 08:19 |
Anonymous (not verified) |
174.217.21.87 |
James Subcontracting |
5212 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. |
2020-07-02 |
James Lee Wardell |
jlw21479@gmail.com |
Des Moines |
IA |
United States |
Tammy Wardell |
Bobby Hoch |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Subcontracting |
jlw21479@gmail.com |
Owner |
Des Moines |
IA |
United States |
Tammy Wardell |
Bobby Hoch |
Signed |
379 |
2022-01-04 14:10 |
Anonymous (not verified) |
97.107.199.129 |
Premier Show Productions |
1304 Skyline Dr Council Bluffs IA |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-20 |
Scott Brandenburg |
scottsuperiorservices@gmail.com |
Council Bluffs |
POtt |
Iowa |
Jan andersen |
Brad Andersen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott Brandenburg |
scottsuperiorservices@gmail.com |
self |
Council Bluffs |
Pott |
Iowa |
Jan Andersen |
Brad Andersen |
Signed |
561 |
2022-11-03 11:24 |
Anonymous (not verified) |
96.31.21.117 |
Northwest 9 Inc. |
1512 Elmwood Ave. |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-11-03 |
Ethan Meyer |
ethanmeyer83@gmail.com |
ROCK RAPIDS |
Iowa |
United States |
Brad Meyer |
Trinda Meyer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Meyer |
nw9farm@gmail.com |
owner |
Rock Rapids |
IA |
United States |
Trinda Meyer |
Brad Meyer |
Signed |
209 |
2021-03-19 11:44 |
Anonymous (not verified) |
206.80.128.67 |
GSW Farms INC |
25277 HWY K45 Onawa, IA 51040 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-19 |
Gregory Willey |
sgwilley@gmail.com |
Onawa |
Monona |
Iowa |
Jacob Willey |
Brad Rock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gregory Willey |
sgwilley@gmail.com |
President |
Onawa |
Monona |
Iowa |
Jacob Willey |
Brad Rock |
Signed |
521 |
2022-07-25 15:33 |
Anonymous (not verified) |
199.66.14.149 |
ROSENBERGER ENTERPRISES, INC. |
1813 N 7th St INDIANOLA, IA 50125 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-07-25 |
Diane Rosenberger |
diane@katanainc.com |
Indianola |
IA |
United States |
SPRING CRUBAUGH |
BRADY FRY |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Diane Rosenberger |
diane@katanainc.com |
Owner |
Indianola |
IA |
United States |
SPRING CRUBAUGH |
BRADY FRY |
Signed |
606 |
2023-02-20 20:55 |
Anonymous (not verified) |
94.188.205.168 |
Carlos Ortiz LLC |
4335 NE 23rd Ave Des Moines, IA 50317 Estados Unidos |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-02-20 |
Carlos Ortiz |
carlosoframing@gmail.com |
Des Moines |
Polk |
Iowa |
Luz picazo |
Brando ortiz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Carlos Ortiz |
carlosograming@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Luz picazo |
Brando Ortiz |
Signed |
810 |
2023-11-09 17:41 |
Anonymous (not verified) |
94.188.205.167 |
Chad Ripple's Painting LLC |
899 NW 45th Ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-09 |
Chad Ripple |
ia515@hotmail.com |
Des Moines |
Polk |
Iowa |
Ron Spurgeon |
Brandon Haus |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chad Ripple |
ia515@hotmail.com |
President |
Des Moines |
Polk |
Iowa |
Ron Spurgeon |
Brandon Haus |
Signed |
809 |
2023-11-08 09:47 |
Anonymous (not verified) |
94.188.207.229 |
GruntWorkz Wedling and Fab, Inc. |
15519 80th Ave Blue Grass, IA 52726 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-08 |
Brandon Joseph Fox |
GruntWorkzwelding@gmail.com |
Blue Grass |
Scott |
Iowa |
Amanda Dawn Fox |
Brandon Joseph Fox |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brandon Joseph Fox |
GruntWorkzwelding@gmail.com |
Same Person |
Blue Grass |
Scott |
Iowa |
Amanda Dawn Fox |
Brandon Joseph Fox |
Signed |
423 |
2022-03-08 12:17 |
Anonymous (not verified) |
173.18.193.171 |
BARNES INC |
1214 40TH ST FORT MADISON IA 52627 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-08 |
dwight barnes |
humburdautoservice455@gmail.com |
Fort Madison |
Iowa |
United States |
Tyson P Barnes |
Brandon L Barnes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
dwight barnes |
humburdautoservice455@gmail.com |
President |
Fort Madison |
Iowa |
United States |
Tyson P Barnes |
Brandon L Barnes |
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 |
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 |
167 |
2021-01-26 11:56 |
Anonymous (not verified) |
74.84.91.178 |
Shea Real Estate LLC |
135 Devon 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. |
2020-12-17 |
Lucas Kahl |
shearealestatellc@gmail.com |
Dubuque |
Dubuque |
Iowa |
Gabe Drewelow |
Brenda Lewis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lucas Kahl |
shearealestatellc@gmail.com |
President |
Dubuque |
Dubuque |
Iowa |
Gabe Drewelow |
Brenda Lewis |
Signed |
168 |
2021-01-26 12:06 |
Anonymous (not verified) |
74.84.91.178 |
RAM Services |
13276 Harvest Mood Ridge, Sherrill, IA 52073 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-11 |
Dusty Herbst |
dustyherbst@hotmail.com |
Sherrill |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dusty Herbst |
dustyherbst@hotmail.com |
President |
Sherrill |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
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 |
232 |
2021-04-12 11:14 |
Anonymous (not verified) |
74.84.91.178 |
Heim Enterprises LLC |
13532 Mueller Parkway, Sherrill, IA 52073 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-01 |
Cory Heim |
corypheim@gmail.com |
Sherrill |
Dubuque |
Iowa |
Gabe Drewelow |
Brenda Lewis |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Cory Heim |
corypheim@gmail.com |
owner |
Sherrill |
Dubuque |
Iowa |
Gabe Drewelow |
Brenda Lewis |
Signed |
110 |
2020-08-25 14:31 |
Anonymous (not verified) |
199.241.229.222 |
Ney Trucking Inc |
5070 Wolff Rd 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. |
2020-08-25 |
Marvin L Ney |
marvin@paramountems.com |
Peosta |
Dubuque |
Iowa |
Karen Ludovissy |
Brenda Weatherwax |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Maria A Ney |
maria@paramountems.com |
Secretary |
Peosta |
Dubuque |
IA |
Karen Ludovissy |
Brenda Weatherwax |
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 |
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 |
871 |
2024-01-26 09:16 |
Anonymous (not verified) |
94.188.205.168 |
NeX Level Restoration |
314 8th St NW, Cedar Rapids, IA, 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-26 |
Trevor McCauley |
jhawktm@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Bridget Camp |
Bridget Camp |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Trevor McCauley |
jhawktm@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Bridget Camp |
Bridget Camp |
Signed |
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 |
924 |
2024-03-19 16:40 |
Anonymous (not verified) |
94.188.207.228 |
Brite-Way Services Inc. |
621 Morningside Dr., Burlington IA 52601 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-19 |
Richard Luckenbill |
britewayburl@gmail.com |
Burlington |
Iowa |
Iowa |
Tammy Luckenbill |
Brooke Mathiasmeier |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Richard Luckenbill |
britewayburl@gmail.com |
Owner, President |
Burlington |
Iowa |
Iowa |
Tammy Luckenbill |
Brooke Mathiasmeier |
Signed |
765 |
2023-09-12 12:44 |
Anonymous (not verified) |
94.188.207.229 |
Southwest Sanitation Inc |
Clarinda, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-09-12 |
Lindsay A Schrock |
swsanitation@gmail.com |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lindsay Schrock |
swsanitation@gmail.com |
Treasure |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
766 |
2023-09-12 12:46 |
Anonymous (not verified) |
94.188.207.224 |
Southwest Sanitation |
Clarinda, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-09-12 |
Craig Schrock |
swsanitation@gmail.com |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lindsay Schrock |
swsanitation@gmail.com |
Treasure |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
767 |
2023-09-12 12:48 |
Anonymous (not verified) |
94.188.207.223 |
Southwest Sanitation |
Clarinda, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-09-12 |
Lonnie Weed |
swsanitation@gmail.com |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lindsay Schrock |
swsanitation@gmail.com |
Treasure |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
769 |
2023-09-12 12:49 |
Anonymous (not verified) |
94.188.207.223 |
Southwest Sanitation |
Clarinda, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-09-12 |
Joshua Weed |
swsanitation@gmail.com |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lindsay Schrock |
swsanitation@gmail.com |
Treasure |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
926 |
2024-03-20 15:25 |
Anonymous (not verified) |
94.188.207.230 |
CML Constuction LLC |
2116 Park Ave Muscatine, Iowa 52761 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-20 |
CHRIS LINNENKAMP |
cmlconstructionllc@gmail.com |
Muscatine |
IA |
IA |
Gabriel Diaz |
Byron Lopez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CHRIS LINNENKAMP |
cmlconstructionllc@gmail.com |
Owner |
Muscatine |
IA |
IA |
Gabriel Diaz |
Byron Lopez |
Signed |
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 |
801 |
2023-10-25 08:32 |
Anonymous (not verified) |
94.188.205.177 |
CEM Businesses LLC |
608 Evergreen Cir NW Bondurant, IA 50035 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-10-25 |
Dane McDonald |
danemcdonald2@gmail.com |
Bondurant |
Polk |
Iowa |
Raelynn Aicher |
Cameron VanBuren |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dane McDonald |
dane.mcdonald@stellar-solar.net |
Self |
Bondurant |
Polk |
Iowa |
Raelynn Aicher |
Cameron VanBuren |
Signed |
803 |
2023-10-25 08:37 |
Anonymous (not verified) |
94.188.205.166 |
CEM Businesses LLC |
608 Evergreen Cir NW Bondurant, IA 50035 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-25 |
Ryan Canales |
ryancanales44@gmail.com |
West Des Moines |
Polk |
Iowa |
Raelynn Aicher |
Cameron VanBuren |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Dane McDonald |
dane.mcdonald@stellar-solar.net |
Self |
Bondurant |
Polk |
Iowa |
Raelynn Aicher |
Cameron VanBuren |
Signed |
848 |
2024-01-05 13:05 |
Anonymous (not verified) |
94.188.205.177 |
NeX Level Moving, LLC |
5634 Deerwood St. SW, Cedar Rapids, IA, 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-05 |
William J Feldmann |
feldmannwng@msn.com |
Anamosa |
Jones |
Iowa |
Bridget |
Camp |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William J Feldmann |
feldmannwng@msn.com |
Self |
Anamosa |
Jones |
Iowa |
Bridget |
Camp |
Signed |
621 |
2023-03-08 07:53 |
Anonymous (not verified) |
94.188.207.223 |
Don Wyckoff Heating Inc. |
95 Highway 5, Carlisle, IA 50047 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-04 |
Michael T Johnson |
mikeyjay1968@gmail.com |
Des Moines |
Polk |
IA |
Brady Cooper |
Carey Cooper |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mike Johnson |
mikeyjay@gmail.com |
Sub-Contractor |
Des Moines |
Polk |
IA |
Brady Cooper |
Carey Cooper |
Signed |
127 |
2020-10-28 14:42 |
Anonymous (not verified) |
104.207.31.201 |
Little Bison Childcar Center, Inc. |
404 2nd St NW |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-10-28 |
Travis Brass |
travis.brass@rakestatesavingsbank.com |
Lakota |
Kossuth |
Iowa |
Tami Jacobson |
Carol Winter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Travis Brass |
travis.brass@rakestatesavingsbank.com |
Treasurer |
Lakota |
Kossuth |
Iowa |
Tami Jacobson |
Carol Winter |
Signed |
661 |
2023-04-29 10:04 |
Anonymous (not verified) |
94.188.205.177 |
Planetary Tree Service |
166 Brovan blvd, evansdale, iowa 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. |
2023-04-29 |
Andrew Jon Collins |
thetreeguy2000@gmail.com |
Evansdale |
Black Hawk |
Iowa |
Jennifer Selleck |
Carolyn Inman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andrew Jon Collins |
thetreeguy2000@gmail.com |
Owner |
Evansdale |
Black hawk |
Iowa |
Jennifer renee selleck |
Carolyn kay Inman |
Signed |
714 |
2023-07-25 16:16 |
Anonymous (not verified) |
94.188.207.224 |
Midwest Systems |
2877 130th St Aurora, Ia 50607 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-07-25 |
Matt Griswold |
midwestsystems@live.com |
Aurora |
IA |
United States |
Creatleigh Griswold |
Carslyn Griswold |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Matt Griswold |
midwestsystems@live.com |
Owner |
Aurora |
IA |
United States |
Creatleigh Griswold |
Carslyn Griswold |
Signed |
747 |
2023-08-19 15:30 |
Anonymous (not verified) |
94.188.207.229 |
Arneson Tree Service |
901 s Washington st Lake Mills IOWA 50450 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-19 |
Charles Douglas Arneson |
charles.arneson@aol.com |
Lake Mills |
Winnebago |
IOWA |
Amber Arneson |
Carter Arneson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Charles Douglas Arneson |
charles.arneson@aol.com |
Owner |
Lake Mills |
Winnebago |
IOWA |
Amber arneson |
Carter Arneson |
Signed |
596 |
2023-02-06 08:08 |
Anonymous (not verified) |
107.121.104.18 |
Household Nanny |
1357 Woolridge Dr., 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. |
2023-02-06 |
Stephen John Statz |
sstatz32@gmail.com |
Coralville |
IA |
United States |
Jeffrey Peterson |
Casey Edwards |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Stephen John Statz |
sstatz32@gmail.com |
Owner |
Coralville |
IA |
United States |
Jeffrey Peterson |
Casey Edwards |
Signed |
597 |
2023-02-06 08:11 |
Anonymous (not verified) |
107.121.104.18 |
Household Nanny |
1357 Woolridge Dr., 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. |
2023-02-06 |
Giselle Marie Statz |
Gisellestatz@gmail.com |
Coralville |
IA |
United States |
Jeffrey Peterson |
Casey Edwards |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Giselle Marie Statz |
gisellestatz@gmail.com |
Owner |
CORALVILLE |
Johnson |
Iowa |
Jeffrey Peterson |
Casey Edwards |
Signed |
583 |
2022-12-09 11:29 |
Anonymous (not verified) |
74.84.79.78 |
Captain Kirk Construction |
202 W Guthrie St. Linden, IA 50146 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-01 |
William Kirj |
iicaptainkirk@gmail.com |
Linden |
Dalas |
Iowa |
Michael O'Conner |
Ron Rand |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William Kirk |
iicaptainkirk@gmail.com |
Owner |
Linden |
Dallas |
IA |
Michael O'Conner |
Casey Kirk |
Signed |
304 |
2021-08-07 03:43 |
Anonymous (not verified) |
50.81.215.27 |
VALLE SERVICES LLC |
6520 N DIVISION 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. |
2021-08-07 |
LAURA VALLE |
iavalleservicesllc@gmail.com |
DAVENPORT |
IA |
United States |
bryon hakes |
celia valle |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LAURA VALLE |
iavalleservicesllc@gmail.com |
owner |
DAVENPORT |
IA |
United States |
bryon hakes |
celia valle |
Signed |
444 |
2022-04-14 15:50 |
Anonymous (not verified) |
72.10.21.42 |
Babcock Services Idaho, Inc. |
8113 W QUINAULT AVENUE 201, Kennewick, WA 99336 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-04-14 |
Carmen Clyde |
CCLYDE@BABCOCKSERVICES.COM |
KENNEWICK |
WA |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CARMEN CLYDE |
CCLYDE@BABCOCKSERVICES.COM |
Secretary |
KENNEWICK |
Benton |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
445 |
2022-04-14 15:52 |
Anonymous (not verified) |
72.10.21.42 |
Babcock Services Idaho, Inc. |
8113 W QUINAULT AVENUE 201, Kennewick, WA 99336 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-04-14 |
Keith Myers |
CCLYDE@BABCOCKSERVICES.COM |
KENNEWICK |
Benton |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CARMEN CLYDE |
CCLYDE@BABCOCKSERVICES.COM |
Secretary |
KENNEWICK |
Benton |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
446 |
2022-04-14 15:54 |
Anonymous (not verified) |
72.10.21.42 |
Babcock Services Idaho, Inc. |
8113 W QUINAULT AVENUE 201, Kennewick, WA 99336 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-04-14 |
Phil Gallagher |
pgallagher@babcockservices.com |
Richland |
Benton |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CARMEN CLYDE |
CCLYDE@BABCOCKSERVICES.COM |
Secretary |
KENNEWICK |
Benton |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
721 |
2023-08-01 09:24 |
Anonymous (not verified) |
94.188.205.167 |
Dryseal Roofing and Construction |
390 Olive St Martensdale, IA 50160 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-01 |
Travis Tibbits |
travistibbits@yahoo.com |
Martensdale |
Warren |
IA |
Hannah Marie Tibbits |
Chad David Walker |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dawn Marie Tibbits |
Tibbits6@gmail.com |
Spouse |
Martensdale |
Warren |
IA |
Hannah Marie Tibbits |
Chad David Walker |
Signed |
439 |
2022-03-29 19:23 |
Anonymous (not verified) |
173.215.72.139 |
Vinton Enterprises LLC |
24704 Isbell Lane, Glenwood, IA 51534 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or 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 |
Holly Vinton |
vintonfive@hotmail.com |
Glenwood |
Mills |
Iowa |
David Pratt |
Chad MIller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Holly Vinton |
vintonfive@hotmail.com |
owner |
Glenwood |
Mills |
Iowa |
David Pratt |
Chad Miller |
Signed |
553 |
2022-10-03 15:32 |
Anonymous (not verified) |
165.206.254.105 |
Ski Mechanical Services |
729 Bell Ave. Des Moines, IA 50315 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-10-03 |
Terry Wave Konchalski |
skiwave79@gmail.com |
Des Moines |
Polk |
Iowa |
Melissa Kerr |
Charlie Ruperto |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Terry Wave Konchalski |
skiwave79@gmail.com |
Owner/President |
Des Moines |
Polk |
Iowa |
Melissa Kerr |
Charlie Ruperto |
Signed |
490 |
2022-06-03 10:14 |
Anonymous (not verified) |
70.96.153.153 |
Reicks Construction Inc |
5415 Alburnett Rd, 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. |
2022-06-03 |
Victor Reicks |
victor@optionsexteriors.com |
Marion |
Linn County |
Iowa |
Austin Miller |
Charlotte Rasmussen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Victor Reicks |
victor@optionsexteriors.com |
Owner |
Marion |
Linn County |
Iowa |
Austin Miller |
Charlotte Rasmussen |
Signed |
705 |
2023-07-06 14:24 |
Anonymous (not verified) |
94.188.205.167 |
Portwood H3D Consulting |
1109 295th Street, Oxford Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-07-06 |
Brian Portwood |
portwoodh3dconsulting@gmail.com |
Oxford |
Johnson |
Iowa |
Bob Herring |
Chelsey Atkinson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brian Portwood |
portwoodh3dconsulting@gmail.com |
owner |
Oxford |
Johnson |
Iowa |
Bob Herring |
Chelsey Atkinson |
Signed |
399 |
2022-02-03 09:03 |
Anonymous (not verified) |
207.199.230.75 |
Heart of Iowa Inspections LLC |
2700 Highway 63 Oskaloosa Iowa 52577 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-02-03 |
Randy DeHeer |
rdeheer2828@gmail.com |
Oskaloosa |
Mahaska |
Iowa |
Doris Crile |
Cheryl Brown |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Randy DeHeer |
rdeheer2828@gmail.com |
self |
Oskaloosa |
Mahaska |
Iowa |
Doris Crile |
Cheryl Brown |
Signed |
55 |
2020-04-06 16:25 |
Anonymous (not verified) |
74.221.44.37 |
Steele Land & Livestock, Inc |
1040 190th St, Anita, IA 50020 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-06 |
Doug Steele |
dsteele@midlands.net |
Anita |
Adair |
Iowa |
Sheryl Leonard |
Cheryl Ellis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Doug Steele |
dsteele@midlands.net |
President |
Anita |
Adair |
Iowa |
Sheryl Leonard |
Cheryl Ellis |
Signed |
332 |
2021-09-13 13:30 |
Anonymous (not verified) |
173.23.250.91 |
Cheri’s roofing |
230 palomino pkwy Des Moines Iowa 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2021-09-13 |
Cheryl Martinez |
cheri6876@yahoo.com |
Des Moines |
Polk |
Iowa |
Cheryl Martinez |
Cheryl martinez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chery Martinez |
cheri6876@yahoo.com |
Owner |
Des Moines |
Polk |
Iowa |
Cheryl Martinez |
Cheryl Martinez |
Signed |
847 |
2024-01-04 21:10 |
Anonymous (not verified) |
94.188.207.227 |
C & L Construction |
721 NE 60th St, Pleasant Hill, IA 50327 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-04 |
Jose M Sanchez Melendez |
landerosmary@gmail.com |
Pleasant Hill |
Polk |
Iowa |
Marianna Landeros |
Cheryl Martinez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jose M Sanchez Melendez |
landerosmary@gmail.com |
Self |
Pleasant Hill |
Polk |
Iowa |
Marianna Landeros |
Cheryl Martinez |
Signed |
678 |
2023-06-06 10:28 |
Anonymous (not verified) |
94.188.205.177 |
William Terrance Harshbarger Jr. |
27225 115th Avenue, Donahue IA 52746 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or 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 |
William Terrance Harshbarger Jr. |
harzyhd1@hotmail.com |
Donahue |
Scott |
Iowa |
Margaret Tucker |
Cheryl Piersall |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William Terrance Harshbarger Jr. |
harzyhd1@hotmail.com |
self |
Donahue |
Scott |
Iowa |
Margaret Tucker |
Cheryl Piersall |
Signed |
679 |
2023-06-06 10:36 |
Anonymous (not verified) |
94.188.205.174 |
William Terrance Harshbarger Jr. |
27225 115th Avenue, Donahue IA 52746 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or 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 |
William Terrance Harshbarger Jr. |
harzyhd1@hotmail.com |
Donahue |
Scott |
Iowa |
Margaret Tucker |
Cheryl Piersall |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William Terrance Harshbarger Jr. |
harzyhd1@hotmail.com |
self |
Donahue |
Scott |
Iowa |
Margaret Tucker |
Cheryl Piersall |
Signed |
428 |
2022-03-23 12:00 |
Anonymous (not verified) |
76.76.231.229 |
Connelly Sanitation Inc |
108 S. 14th St. Fairfield IA 52556 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-23 |
Richard Raymond Vogt |
connelly.inc@outlook.com |
Fairfield |
Jefferson |
Iowa |
Mindy Lynn Vogt |
Chester James Vogt |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Richard Raymond Vogt |
connelly.inc@outlook.com |
Self |
Fairfield |
Jefferson |
Iowa |
Mindy Lynn Vogt |
Chester James Vogt |
Signed |
623 |
2023-03-08 13:48 |
Anonymous (not verified) |
94.188.205.174 |
Jim & Laini's Trucking Inc |
11591 Rupp Hollow 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. |
2023-03-08 |
James Harry |
jltiowa@gmail.com |
DUBUQUE |
IA |
United States |
Christopher T Clarke |
Chris Clarke |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Harry |
jltiowa@gmail.com |
owner |
DUBUQUE |
IA |
United States |
Christopher T Clarke |
Chris Clarke |
Signed |
624 |
2023-03-08 13:50 |
Anonymous (not verified) |
94.188.205.177 |
Jim & Laini's Trucking Inc |
11591 Rupp Hollow 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. |
2023-03-08 |
Elaine Harry |
jltiowa@gmail.com |
DUBUQUE |
Iowa |
United States |
Christopher T Clarke |
Chris Clarke |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Harry |
jltiowa@gmail.com |
owner |
DUBUQUE |
IA |
United States |
Christopher T Clarke |
Chris Clarke |
Signed |
952 |
2024-04-08 17:25 |
Anonymous (not verified) |
94.188.205.175 |
Bio-Inspired Design Aeronautics Corp |
6843 Still Creek Pass |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-08 |
Joseph Mitchell |
aerotech@hush.com |
Bettendorf |
Iowa |
United States |
Mike Owens |
Chris DeCock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Hollie Mitchell |
mitchhollie@yahoo.com |
Vice President |
Bettendorf |
Iowa |
United States |
Mike Owens |
Chris DeCock |
Signed |
953 |
2024-04-08 17:35 |
Anonymous (not verified) |
94.188.205.174 |
Bio-Inspired Design Aeronautics Corp |
6843 Still Creek Pass |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-08 |
Hollie Mitchell |
mitchhollie@yahoo.com |
Bettendorf |
Iowa |
United States |
Mike Owens |
Chris DeCock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph Mitchell |
aerotech@hush.com |
President |
Bettendorf |
Iowa |
United States |
Mike Minnich |
Chris DeCock |
Signed |
954 |
2024-04-08 17:38 |
Anonymous (not verified) |
94.188.205.168 |
Bio-Inspired Design Aeronautics Corp |
6843 Still Creek Pass |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-08 |
Hailey Mitchell |
hailey8.hm@hush.com |
Bettendorf |
Iowa |
United States |
Mike Owens |
Chris DeCock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph Mitchell |
aerotech@hush.com |
President |
Bettendorf |
Iowa |
United States |
Mike Minnich |
Chris DeCock |
Signed |
668 |
2023-05-12 10:14 |
Anonymous (not verified) |
94.188.205.166 |
Design Drywall Inc. |
PO Box 457 Tiffin, IA 52340 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-05-12 |
Rudy Gonzalez |
designdrywallinc19@gmail.com |
Tiffin |
Johnson |
Iowa |
Brad Bower |
Chris Hay |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rudy Gonzalez |
designdrywallinc19@gmail.com |
President |
Tiffin |
Johnson |
Iowa |
Brad Bower |
Chris Hay |
Signed |
510 |
2022-07-12 09:13 |
Anonymous (not verified) |
174.198.70.141 |
Premiere Painting, LLC |
865 NE Bobcat Dr Waukee, IA. 50263 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-07-12 |
Scott McVay |
scottkmcvay@live.com |
Waukee |
Dallas |
Iowa |
Robert Ferguson |
Christina Pham |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott McVay |
scottkmcvay@live.con |
Owner |
Waukee |
Dallas |
Iowa |
Robert Ferguson |
Christina Pham |
Signed |
207 |
2021-03-16 08:34 |
Anonymous (not verified) |
63.152.54.231 |
Iowa Express Delivery Service Inc. |
4021 Old Ferry Road |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-16 |
Karen Stearns |
iowaexpressdelivery@gmail.com |
Palo |
Linn |
United States |
Jeremiah Morris |
Christina Stearns |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Karen Stearns |
iowaexpressdelivery@gmail.com |
Self |
Palo |
Linn |
United States |
Jeremiah Morris |
Christina Stearns |
Signed |
303 |
2021-08-06 10:12 |
Anonymous (not verified) |
173.28.219.60 |
Travis Systems, Inc. |
2060 Lynncrest Dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-06 |
Travis Remmert |
travis@travissystems.com |
Coralville |
IA |
United States |
Michelle Remmert |
Christine Douglas |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Travis Remmert |
travis@travissystems.com |
President & CEO |
Coralville |
IA |
United States |
Michelle Remmert |
Christine Douglas |
Signed |
632 |
2023-03-22 13:44 |
Anonymous (not verified) |
94.188.205.177 |
Midwest Home Solutions Inc |
150 Light Rd., 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. |
2023-03-22 |
Ean Michael Caskey |
ean_caskey@hotmail.com |
Lisbon |
Linn |
IA |
Trista Leigh Schaffner |
Christopher Ray Schaffner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ean Michael Caskey |
ean_caskey@hotmail.com |
President |
Lisbon |
Linn |
Iowa |
Trista Leigh Schaffner |
Christopher Ray Schaffner |
Signed |
450 |
2022-04-20 13:42 |
Anonymous (not verified) |
96.85.81.137 |
D&K Harvesting Inc. |
P.o Box 1347 LaBelle Fl 33975 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-04-20 |
James Larry Marsh Jr |
larrym3041@aol.com |
Fort myers |
Lee |
Florida |
Anita Coronado |
Christy Pequeno |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
James Larry Marsh Jr |
larrym3041@aol.com |
Owner |
Fort myers |
Lee |
Florida |
Anita Coronado |
Christy Puequeno |
Signed |
675 |
2023-05-24 07:55 |
Anonymous (not verified) |
94.188.207.223 |
Sierra Roofing |
401 W 15th Street West Liberty, IA 52776 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-05-24 |
Abraham Granjeno Sierra |
sierraroofing@gmail.com |
West Liberty |
Muscatine |
Iowa |
Cody Thorpe |
Claudia Venable |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Abraham Granjeno Sierra |
sierraroofing@gmail.com |
Owner/Self |
West Liberty |
Muscatine |
Iowa |
Cody Thorpe |
Claudia Venable |
Signed |
297 |
2021-07-30 11:05 |
Anonymous (not verified) |
165.225.60.212 |
Love Tap Racing LLC |
1122 Sunset Ave, Kelley, IA 50134 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-07-30 |
Timothy Love |
tiredemon@gmail.com |
Kelley |
Story |
IA |
Katie Frame |
Cody Jones |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Timothy Love |
tiredemon@gmail.com |
Owner |
Ames |
Story |
IA |
Katie Frame |
Cody Jones |
Signed |
298 |
2021-07-30 11:05 |
Anonymous (not verified) |
165.225.60.212 |
Love Tap Racing LLC |
1122 Sunset Ave, Kelley, IA 50134 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-07-30 |
Laura Love |
tiredemon@gmail.com |
Kelley |
Story |
IA |
Katie Frame |
Cody Jones |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Laura Love |
tiredemon@gmail.com |
Owner |
Ames |
Story |
IA |
Katie Frame |
Cody Jones |
Signed |
378 |
2022-01-03 15:16 |
Anonymous (not verified) |
217.180.230.157 |
True360, Inc. |
1805 Collaboration Place, Suite 1300, Ames, Iowa 50010 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-03 |
Christopher James |
chris@true-360.com |
Ames |
Iowa |
United States |
Jesse Kisker |
Cody Kapka |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christopher James |
chris@true-360.com |
President and Chief Executive Officer |
Ames |
Iowa |
United States |
Jesse Kisker |
Cody Kapka |
Signed |
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 |
334 |
2021-09-14 16:24 |
Anonymous (not verified) |
67.129.252.2 |
Nextec |
4050 Westmark Drive, Dubuque, Iowa 52002 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-14 |
Susan Kern |
skern@kendallhunt.com |
Dubuque |
Dubuque |
Iowa |
Paul Kern |
Matthew Johnston |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Greg Feltes |
gfeltes@westmarkdevelopment.com |
Officer |
Dubuque |
Dubuque |
Iowa |
Dana Feltes |
Cole Feltes |
Signed |
500 |
2022-06-22 15:55 |
Anonymous (not verified) |
206.125.132.254 |
Cozad Trucking Inc |
2272 W River Dr, Davenport, IA 52802 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-22 |
David Cozad |
jeepd856@gmail.com |
Davenport |
Scott |
Iowa |
Brett Nelson |
Colleen Heiser |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Cozad |
jeepd856@gmail.com |
Owner |
Davenport |
Scott |
IA |
Brett Nelson |
Colleen Heiser |
Signed |
873 |
2024-01-26 12:02 |
Anonymous (not verified) |
94.188.207.224 |
Bowlerama, Inc. |
1313 East Diehl St. Des Moines, IA 50315 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-26 |
Michael Klimpel |
Klimpel@aol.com |
Rosemount |
MN |
United States |
Eric Stahl |
Connie Hill |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Michael Klimpel |
Klimpel@aol.com |
President |
Rosemount |
MN |
United States |
Eric Stahl |
Connie Hill |
Signed |
193 |
2021-03-02 11:32 |
Anonymous (not verified) |
50.83.72.164 |
4 corners drywall |
532 w 15 st, Davenport, iowa 52803 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2021-03-02 |
Phillip hoxsey |
Phillhoxsey81@gmail.com |
Davenport |
Scott |
Iowa |
Donivan hoxsey |
Connor ruge |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Phillip hoxsey |
Phillhoxsey81@gmail.com |
Owner |
Davenport |
Scott |
Iowa |
Donivan hoxsey |
Connor ruge |
Signed |
194 |
2021-03-02 11:42 |
Anonymous (not verified) |
50.83.72.164 |
D’s Drywall |
1217 n Blanchard 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. |
(2) I decline to reject the employer’s liability coverage. |
2021-03-02 |
Donivan hoxsey |
hdonivan@gmail.com |
Davenport |
Scott |
Iowa |
Phillip hoxsey |
Connor ruge |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Donivan hoxsey |
hdonivan@gmail.com |
Owner |
Davenport |
Scott |
Iowa |
Phillip hoxsey |
Connor ruge |
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 |
371 |
2021-12-09 11:03 |
Anonymous (not verified) |
216.81.176.153 |
Concentric International Inc. |
1901 Bell Ave Ste 18, Des Moines, IA 50315-1067 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-12-09 |
Tracey Ball |
tball@ruan.com |
Urbandale |
IA |
United States |
Jackie Walker |
Craig Gesme |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tracey Ball |
tball@ruan.com |
Treasurer |
Urbandale |
IA |
United States |
Jackie Walker |
Craig Gesme |
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 |
774 |
2023-09-21 10:21 |
Anonymous (not verified) |
94.188.205.167 |
Tri State Trucking LLC |
47282 US Hwy 20 Atkinson, NE 68713 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-09-21 |
Casey Schaaf |
casey@tri-statetrucking.com |
Atkinson |
Holt |
NE |
Angela Schaaf |
Crystal Osborne |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Casey Schaaf |
casey@tri-statetrucking.com |
Owner |
Atkinson |
Holt |
NE |
Angela Schaaf |
Crystal Osborne |
Signed |