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Rejection of Workers' Compensation or Employers' Liability Coverage

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# Submitted User IP address Name of Corporation: Address of Corporation Home Office: Statement 1 Agreement: Statement 2 Agreement: Statement 3 Agreement: Statement Agreement: Check Either Alternative (1) or (2): Date: Full Name of Individual: Email: City of Residence: County of Residence: State of Residence: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Agreement: Alternative Selection: Full Name of Authorized Agent: Email of Authorized Agent: Relationship to Corporation of Authorized Agent: City of Residence: County of Residence: State: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Indication:
593 2023-01-30 10:39 Anonymous (not verified) 69.18.9.193 ABC Fire Extinguisher Sales & Service, Inc. 112 Broadway Street Suite 2, West Burlington, IA 52655 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-01 Derek Stotlar contactabc@abc-fire.com Sperry Des Moines IA Kori Stotlar Jeff Elliott Signed (1) The corporation rejects the employers’ liability coverage. Kori Stotlar kstotlar@abc-fire.com President Sperry Des Moines IA Jeff Elliott Kim Eland Signed
592 2023-01-22 11:29 Anonymous (not verified) 216.106.211.176 Trackside Service & Repair Inc. 205 Main St. Alvord, IA 51230 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-22 Renee J Klarenbeek dkranch@alliancecom.net Rock Rapids Iowa United States Steve C. Green Darwyn G. Klarenbeek Signed (1) The corporation rejects the employers’ liability coverage. Darwyn G. Klarenbeek trackside@alliancecom.net Owner Rock Rapids Lyon IA Steve C. Green Darwyn G. Klarenbeek Signed
591 2023-01-22 11:19 Anonymous (not verified) 216.106.211.176 Trackside Service & Repair Inc. 205 Main St. Alvord, IA 51230 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-22 Darwyn G Klarenbeek trackside@alliancecom.net Rock Rapids Lyon United States Steve Green Renee Klarenbeek Signed (1) The corporation rejects the employers’ liability coverage. Darwyn G Klarenbeek trackside@alliancecom.net Owner Rock Rapids IA United States Steve C. Green Renee J Klarenbeek Signed
590 2023-01-18 15:14 Anonymous (not verified) 172.86.13.54 BOLT HOLDINGS, Inc and Holt Precision dba Holt Bladeworks and Holt Kinetic Solutions 3230 N Center Point Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-18 Carter Kramer Carter@Holtkineticsolutions.com Cedar Rapids Linn Iowa Lisa Gleason Tricia Kummer Signed (1) The corporation rejects the employers’ liability coverage. Lisa Gleason Lisa@Holtkineticsolutions.com General Manager Marion Linn Iowa Tricia Kummer Marla McFall Signed
589 2023-01-16 10:18 Anonymous (not verified) 174.130.20.253 HCS Trucking LLC 403 Date St 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. 2023-01-16 Jamie Hedstrom hedstromcrane@gmail.com Schleswig Crawford Iowa Noah Hedstrom Landa Hedstrom Signed (2) The corporation declines to reject the employers’ liability coverage. Jamie Hedstrom hedstromcrane@gmail.com owner Schleswig Crawford Iowa Noah Hedstrom Landa Hedstrom Signed
588 2023-01-13 10:49 Anonymous (not verified) 173.17.248.155 Cheri's Roofing 1842 Glenwood Circle Des Moines, IA 50320 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-13 Cheryl Martinez cheri6876@yahoo.com Des Moines Polk Iowa Jessica L Newton Thomas C Newton Signed (1) The corporation rejects the employers’ liability coverage. Cheryl Martinez cheri6876@yahoo.com Owner Des Moines Polk Iowa Jessica L Newton Thomas C Newton Signed
587 2023-01-09 10:04 Anonymous (not verified) 173.27.230.122 Hatfield Co Inc 307 E 20th St Box 185 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-09 Brenda Hatfield brenmarie137.bh@gmail.com Lovilia IA United States Jerry Griffin Dave Chesnut Signed (1) The corporation rejects the employers’ liability coverage. Boyle and Henderson joycem@boyleandhenderson.com Accountant Oskaloosa Marion Iowa Jerry Griffin Dave Chesnut Signed
586 2022-12-16 15:53 Anonymous (not verified) 184.184.197.146 Halide Biologics 330 Golfview Ave, Iowa City IA 52246 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-12-15 Daniel Infield danielinfield@gmil.com Bennington Douglas Nebraska Alexander Estell Jesse Herrera Signed (1) The corporation rejects the employers’ liability coverage. Daniel Infield danielinfield@gmail.com President Bennington NE United States Alexander Estell Jesse Herrera Signed
585 2022-12-15 20:32 Anonymous (not verified) 192.110.196.132 Maywood Enterprises, Inc. 28345 Highway 52, Bellevue, IA 52031 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-12-15 Ann L Wachtel annw@financepro123.com Bellevue Jackson Iowa Katie Laban Jeffrey Laban Signed (1) The corporation rejects the employers’ liability coverage. Ann L Wachtel annw@financepro123.com President Bellevue Jackson IA Katie Laban Jeffrey Laban Signed
584 2022-12-09 11:34 Anonymous (not verified) 74.84.79.78 Luis Avila Zermeno 2457 E Kenyon Ave. Des Moines, IA 50320 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-01 Luis Avila Zermeno propainters-17@icloud.com Des Moines Polk Iowa Fatima Mendoza William Kirk Signed (1) The corporation rejects the employers’ liability coverage. Luis Avila Zermeno propainters-17@icloud.com Owner Des Moines Polk IA Fatima Mendoza William Kirk 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
582 2022-12-09 11:26 Anonymous (not verified) 74.84.79.78 Diamond Does It LLC 3945 38th St. Des Moines, IA 50310 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-01 Daimond Martinez diamonddoesitdsm@gmail.com Des Moines Polk Iowa Michael O'Conner Ron Rand Signed (1) The corporation rejects the employers’ liability coverage. Diamond Martinez diamonddoesitdsm@gmail.com Owner Des Moines Polk Iowa Michael O'Conner Ron Rand Signed
581 2022-12-09 11:23 Anonymous (not verified) 74.84.79.78 Avila Gutters 5901 SW 5th 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. 2022-01-01 Enrique Avila Ceballos enrique86avila@gmail.com Des Moines Polk Iowa Michael O'Conner Ron Rand Signed (1) The corporation rejects the employers’ liability coverage. Enrique Avila Ceballos enrique86avila@gmail.com Owner Des Moines Polk Iowa Michael O'Conner Ron Rand Signed
580 2022-12-09 11:20 Anonymous (not verified) 74.84.79.78 Aaron Alley 101 Teale St. Davis City, IA 50065 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-01 Aaron Alley alleyre@hotmail.com Davis City Decatur Iowa Michael O'Conner Ron Rand Signed (1) The corporation rejects the employers’ liability coverage. Aaron Alley alleyre@hotmail.com owner Davis City Decatur Iowa Michael O'Conner Ron Rand Signed
579 2022-12-07 14:37 Anonymous (not verified) 96.31.1.206 IGL RENTAL LLC PO BOX 317 ARNOLDS PARK IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-10-25 CHAD JONES STAYBOJI@GMAIL.COM ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The corporation rejects the employers’ liability coverage. CHAD JONES STAYBOJI@GMAIL.COM MEMBER ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
578 2022-12-05 09:45 Anonymous (not verified) 184.185.80.106 John A. Paul Consulting, LLC 40962 Brothers Ave, Henderson, IA 51541 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-12-05 John A. Paul johnaddisonpaul1@gmail.com Henderson Mills County Iowa Paul Wilson Melanie Donegan Signed (1) The corporation rejects the employers’ liability coverage. John A. Paul johnaddisonpaul1@gmail.com President Henderson Mills County Iowa Paul Wilson Melanie Donegan Signed
577 2022-12-02 12:31 Anonymous (not verified) 74.84.79.78 Juan A. Martinez-Salazar 7085 Bloomfield Rd. Des Moines, IA 50320 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-02 Juan A. Martinez Salazar bananas94@icloud.com Des Moines Polk IA Racio Rodriguez Manuel Gonzalez Signed (1) The corporation rejects the employers’ liability coverage. Juan A. Martinez- Salazar bananas94@icloud.com President Des Moines Polk IA Racio Rodriguez Manuel Gonzales Signed
576 2022-12-01 10:54 Anonymous (not verified) 97.125.244.8 R A Snow Removals, Inc 525 7th St NW, Altoona, IA 50009 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-12-01 Robert Aaron Snow snowelectric22@gmail.com Altoona Polk Iowa Shannon Keely Moses Jameson Robert Snow Signed (1) The corporation rejects the employers’ liability coverage. Robert Aaron Snow snowelectric22@gmail.com Owner Altoona Polk Iowa Shannon Keely Moses Jameson Robert Snow Signed
575 2022-11-18 14:01 Anonymous (not verified) 204.155.61.217 County Line Drainage Inc 806 Milton Ave, Lake Mills, IA 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. 2022-11-18 Brian Helgeson dgust@mbtbank.com Lake Mills Winnebago Iowa Douglas Gust Lee Lambert Signed (1) The corporation rejects the employers’ liability coverage. Brian Helgeson brianshelgeson@gmail.com President Lake mills Winnebago Iowa Douglas Gust Lee Lambert Signed
574 2022-11-17 16:48 Anonymous (not verified) 204.16.59.133 Washland, Inc. 4050 W Schrock Rd, Hudson, IA 50643 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-17 Joel Steven Barfels joel@laundryplusiowa.com Hudson Black Hawk Iowa Vicki Lorraine Barfels Steven Douglas Barfels Signed (1) The corporation rejects the employers’ liability coverage. Vicki Lorraine Barfels vicki@laundryplusiowa.com Corporate Treasurer Hudson Black Hawk Iowa Vicki Lorraine Barfels Steven Douglas Barfels Signed
573 2022-11-17 16:46 Anonymous (not verified) 204.16.59.133 Washland, Inc. 4050 W Schrock Rd, Hudson, IA 50643 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-17 Vicki Lorraine Barfels vicki@laundryplusiowa.com Hudson Black Hawk Iowa Joel Steven Barfels Steven Douglas Barfels Signed (1) The corporation rejects the employers’ liability coverage. Joel Steven Barfels joel@laundryplusiowa.com Corporate Secretary Hudson Black Hawk Iowa Joel Steven Barfels Steven Douglas Barfels Signed
572 2022-11-17 16:43 Anonymous (not verified) 204.16.59.133 Washland, Inc. 4050 W Schrock Rd, Hudson, IA 50643 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-17 Steven Douglas Barfels getclean@laundryplusiowa.com Hudson Black Hawk Iowa Joel Steven Barfels Vicki Lorraine Barfels Signed (1) The corporation rejects the employers’ liability coverage. Joel Steven Barfels joel@laundryplusiowa.com Corporate Secretary Hudson Black Hawk Iowa Joel Steven Barfels Vicki Lorraine Barfels Signed
571 2022-11-16 10:40 Anonymous (not verified) 50.81.253.108 XU's Golden Dragon 508 Chestnut St., Atlantic, IA 50022 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-16 Tingjie Huang 125529647@QQ.COM Atlantic Cass IA Richard Crall Shannon Crall Signed (1) The corporation rejects the employers’ liability coverage. Richard Crall richard@partnersins.com Insurance Agent Atlantic Cass United States Shannon Crall Richard Crall Signed
570 2022-11-16 10:35 Anonymous (not verified) 50.81.253.108 XU's Golden Dragon 508 Chestnut St., Atlantic, IA 50022 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-16 Xu Long 125529647@QQ.COM Atlantic Cass IA Richard Crall Shannon Crall Signed (1) The corporation rejects the employers’ liability coverage. Richard Crall richard@partnersins.com Insurance Agent Atlantic Cass United States Shannon Crall Richard Crall Signed
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
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
567 2022-11-14 18:21 Anonymous (not verified) 166.181.83.71 Beasts Bussiness 1305 N 6th St Apt. 6 Indianola, IA 50125 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-14 Jonathan Brice Robinson Beastsbeekeeping@gmail.com Indianola Warren Iowa Timothy Williams Robinson Josiah Grant Robinson Signed (1) The corporation rejects the employers’ liability coverage. Jonathan Brice Robinson Beastsbeekeeping@gmail.com Owner Indianola Warren Iowa Timothy Williams Robinson Josiah Grant Robinson Signed
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
565 2022-11-14 08:22 Anonymous (not verified) 97.119.175.158 CenterLine Electric Inc 22004 185th St Council Bluffs IA I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-14 Jonathon w Haldeman centerline.electric@yahoo.com council bluffs pottawattamie Iowa cathy haldeman koleen haldeman Signed (1) The corporation rejects the employers’ liability coverage. jonathon haldeman centerline.electric@yahoo.com owner council bluffs pottawattamie iowa cathy haldeman koleen haldeman Signed
564 2022-11-12 13:05 Anonymous (not verified) 152.117.104.212 ArborSharp Tree Care LLC 125 South Russell Ave Ames IA 50010 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-12 Jonathan Michael Ostermann arborsharptc@gmail.com Ames IA IA Ben Wyatt Marc McClanahan Signed (1) The corporation rejects the employers’ liability coverage. Jonathan Ostermann arborsharptc@gmail.com owner Ames story IA Ben Wyatt Marc McClanahan Signed
563 2022-11-09 10:28 Anonymous (not verified) 199.168.243.195 Mensingers Aquatic Resources, Inc. 2119 Oak Trail Drive I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-09 Jeff Mensinger jeffrey.mensinger@hdrinc.com Camanche ia United States Cody Mensinger Jeremiah Haas Signed (1) The corporation rejects the employers’ liability coverage. Jeff Mensinger jeffrey.mensinger@hdrinc.com President Camanche ia United States Cody Mensinger Jeremiah Haas Signed
562 2022-11-04 10:32 Anonymous (not verified) 98.159.123.124 Alli-Center 555 Cameron Way Unit 2 North Liberty Iowa 52317 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-04 Bonnie Seely bseely4@gmail.com Cedar Rapids Linn Iowa Jonah C Seely Hannah Seely Signed (1) The corporation rejects the employers’ liability coverage. Bonnie Seely bseely4@gmail.com Owner/Self Cedar Rapids Linn Iowa Jonah Seely Hannah Seely Signed
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
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
559 2022-10-24 15:14 Anonymous (not verified) 108.178.192.251 LogicBox, Inc. 2381 Highway 169, Winterset, IA 50273 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-10-24 Jeremy Goemaat jeremy.goemaat@gmail.com Winterset Madison Iowa Janelle Goemaat Gunnar Goemaat Signed (1) The corporation rejects the employers’ liability coverage. Jeremy Goemaat jeremy.goemaat@gmail.com CEO/Owner Winterset Madison Iowa Janelle Goemaat Gunnar Goemaat Signed
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
557 2022-10-17 09:23 Anonymous (not verified) 67.22.198.94 Baker Irrigation Inc. 2621 310th St. Rock Valley, IA 51247 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-10-17 Alex DeJager alex@bakerirrigationia.com Rock Valley Sioux Iowa Jesse Niemeyer Herlan DeJager Signed (1) The corporation rejects the employers’ liability coverage. Alex DeJager alex@bakerirrigationia.com Co-Owner Rock Valley Sioux Iowa Jesse Niemeyer Herlan DeJager Signed
556 2022-10-12 14:02 Anonymous (not verified) 204.155.61.217 Embassy Catering, Inc PO Box 2805 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-23 Ron Godwin ronjgodwin@aol.com Cedar Rapids Linn Iowa Molly Feldman Sharon Naber Signed (1) The corporation rejects the employers’ liability coverage. Embassy Catering, Inc. ronjgodwin@aol.com president Cedar Rapids Linn Iowa Molly Feldman Sharon Naber 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
554 2022-10-03 15:44 Anonymous (not verified) 75.162.176.251 SBM Construction Inc 3023 1st 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. 2022-09-03 Mike Guerrero service@fritzins.com Des Moines Polk Iowa David Fritz Matthew Fritz Signed (1) The corporation rejects the employers’ liability coverage. Mike Guerrero service@fritzins.com Owner Des Moines Polk Iowa David Fritz Matthew Fritz 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
552 2022-10-03 11:50 Anonymous (not verified) 173.18.48.197 Rancheros construction LLC 1121 Linn Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-25 Salvador Alvarez rancherosconstruction@outlook.com Waterloo Black hwak Iowa Jose Sergio Signed (1) The corporation rejects the employers’ liability coverage. Salvador Alvarez rancherosconstruction@outlook.com N/a Waterloo Black hawk Iowa Jose Sergio Signed
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
550 2022-09-29 09:10 Anonymous (not verified) 208.126.212.128 City of Leland 316 Walnut St., PO Box 127, Leland, IA 50453 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-29 Russell Leitz rkleitz@wctatel.net Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed (1) The corporation rejects the employers’ liability coverage. Dawn Arispe leland@wctatel.net City of Leland City Clerk Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed
549 2022-09-29 09:08 Anonymous (not verified) 208.126.212.128 City of Leland 316 Walnut St., PO Box 127, Leland, IA 50453 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-29 Jesse O'Toole jesseotoole7@gmail.com Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed (1) The corporation rejects the employers’ liability coverage. Dawn Arispe leland@wctatel.net City of Leland City Clerk Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed
548 2022-09-29 09:06 Anonymous (not verified) 208.126.212.128 City of Leland 316 Walnut St., PO Box 127, Leland, IA 50453 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-29 Rex Johnson rexr@wctatel.net Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed (1) The corporation rejects the employers’ liability coverage. Dawn Arispe leland@wctatel.net City of Leland City Clerk Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed
547 2022-09-29 09:04 Anonymous (not verified) 208.126.212.128 City of Leland 316 Walnut St., PO Box 127, Leland, IA 50453 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-29 Ken Steil leland@wctatel.net Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed (1) The corporation rejects the employers’ liability coverage. Dawn Arispe leland@wctatel.net City of Leland City Clerk Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed
546 2022-09-29 09:02 Anonymous (not verified) 208.126.212.128 City of Leland 316 Walnut St., PO Box 127 Leland, IA 50453 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-29 Susan Krein skkrein@gmail.com Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed (1) The corporation rejects the employers’ liability coverage. Dawn Arispe leland@wctatel.net City of Leland City Clerk Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed
545 2022-09-29 08:59 Anonymous (not verified) 208.126.212.128 City of Leland 316 Walnut St., Leland, IA 50453 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-29 Marsha Casler mandrcasler@hotmail.com Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed (1) The corporation rejects the employers’ liability coverage. Dawn Arispe leland@wctatel.net City Clerk of Leland Leland Iowa United States Roger Torkelson Kelly Bendickson Signed
544 2022-09-27 09:00 Anonymous (not verified) 204.155.61.217 Four Guys Auto, Inc. 4705 Johnson Ave NW, Cedar Rapids, IA 52405 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-27 Scott Atwood office@fourguysauto.com Cedar Rapids Linn Iowa Sharon Naber Molly Feldman Signed (1) The corporation rejects the employers’ liability coverage. Scott Atwood office@fourguysauto.com President Van Horne Benton Iowa Sharon Naber Molly Feldman Signed
543 2022-09-27 08:52 Anonymous (not verified) 204.155.61.217 Ron Godwin, Inc PO Box 2805, Cedar Rapids, IA 52406 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-27 Ron Godwin ronjgodwin@aol.com Cedar Rapids Linn Iowa Molly Feldman Sharon Naber Signed (1) The corporation rejects the employers’ liability coverage. Ron Godwin, Inc ronjgodwin@aol.com president Cedar Rapids Linn Iowa Molly Feldman Sharon Naber Signed
542 2022-09-26 19:26 Anonymous (not verified) 45.78.142.139 Doyle Vondrak Trucking 315 Vermont Avenue, Kingsley, Iowa 51028 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-26 Doyle P Vondrak dpvondrak@wiatel.net Kingsley Plymouth Iowa Jayne R Vondrak Jesse M Vondrak Signed (1) The corporation rejects the employers’ liability coverage. Doyle P Vondrak dpvondrak@wiatel.net self-employed; single employee Kingsley Plymouth Iowa Jayne R Vondrak Jesse M Vondrak Signed
541 2022-09-23 13:13 Anonymous (not verified) 184.80.177.137 Tim & Lori Daly 25430 New Vienna Rd - Farley, IA 52046 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-23 Tim Daly jheims@english-insurance.com Dyersville Dubuque IA Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque IA Derrick Parsons Joyce Heims Signed
540 2022-09-22 18:48 Anonymous (not verified) 172.58.84.145 José j Castañeda lara 1722 22st 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. 2022-09-22 José j Castañeda lara jesuscastaneda28@gmail.com Des Moines Polk Iowa Joseph Powell Jesica Powell Signed (1) The corporation rejects the employers’ liability coverage. José j Castañeda lara jesuscastaneda28@gmail.com Self Des Moines Polk Iowa Joseph Powell Jesica Powell Signed
539 2022-09-22 18:03 Anonymous (not verified) 166.181.87.86 Abarrotes La Salud, Inc. 17 North 1st 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. (2) I decline to reject the employer’s liability coverage. 2022-09-22 Gabriela Vargas Avalos mtownlasalud@gmail.com Marshalltown Marshall Iowa Antonio Ramirez Sanchez Genoveva Alvizu Hernandez Signed (2) The corporation declines to reject the employers’ liability coverage. Gabriela Vargas Avalos mtownlasalud@gmail.com Vice President Marshalltown Marshall Iowa Antonio Ramirez Sanchez Genoveva Alvizu Hernandez Signed
538 2022-09-21 17:04 Anonymous (not verified) 174.198.67.151 Premiere Painting, LLC 865 NE Bobcat 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. 2022-09-21 Scott McVay premierepainting515@gmail.com Waukee Dallas Iowa Christina Pham Robert Ferguson Signed (1) The corporation rejects the employers’ liability coverage. Scott McVay premierepainting515@gmail.com Owner Waukee Dallas Iowa Christina Pham Robert Ferguson 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
536 2022-09-16 09:56 Anonymous (not verified) 65.155.194.4 Tectum Construction and Roofing Inc. 1623 Thetford Cir Orlando FL 32824 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-16 Segundo Sanchez fsanchez@tectumconstruction.com Orlando Fl United States Chris Becker Dereck Bolten Signed (1) The corporation rejects the employers’ liability coverage. Segundo Sanchez fsanchez@tectumconstruction.com CEO ORLANDO Orange Florida Chris Becker Dereck Bolten Signed
535 2022-09-15 10:01 Anonymous (not verified) 173.25.103.95 Hillcreek Livestock Co. 721 460th Ave Grinnell, IA 50122 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-08-25 Levi Hoksbergen pslcorp@zumatel.net Grinnell Poweshiek IA Jared Vincent Kevin Corn Signed (1) The corporation rejects the employers’ liability coverage. Levi Hoksbergen pslcorp@zumatel.net Owner Grinnell Poweshiek IA Jared Vincent Kevin Corn Signed
534 2022-09-09 08:35 Anonymous (not verified) 192.95.125.128 Darri, Inc. 903 W 4th Street, Vinton, IA 52349 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-09 Teri Jo Sellers teri@bobbinsandboards.com Vinton Benton Iowa Hanna Gregory Jennie Lynn Roster Signed (1) The corporation rejects the employers’ liability coverage. Darran Kenneth Sellers darran.sellers@mrhandyman.com President Vinton Benton Iowa Hanna Gregory Jennie Lynn Roster Signed
533 2022-09-08 11:04 Anonymous (not verified) 174.198.66.66 WCDEVINE LLC dba Five Star Painting of Cedar Falls 6333 Leversee 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. 2022-09-08 Wade Devine (owner) Wade.Devine@fivestarpainting.com Waterloo Blackhawk Iowa Brad Johnson Tom Wildeboer Signed (1) The corporation rejects the employers’ liability coverage. Wade Devine Wade.Devine@fivestarpainting.com Owner/Same person Waterloo Blackhawk Iowa Brad Johnson Tom Wildeboer Signed
532 2022-09-07 12:42 Anonymous (not verified) 217.180.226.147 Practical Farmers of Iowa 1615 Golden Aspen Dr., Suite 101, Ames, IA 50010 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-07 Jonathan Bakehouse jon@mapleedgefarm.com Hastings Mills Iowa Jeanne-Marie Bakehouse DeWayne Kroledge Signed (1) The corporation rejects the employers’ liability coverage. Sally Worley sally@practicalfarmers.org Executive Director Ames Story United States Jeann-Marie Bakehouse DeWayne Kroledge Signed
531 2022-09-02 13:19 Anonymous (not verified) 173.20.146.6 Nicci Keck LLC 1107 Pheasant Valley St, Iowa City, IA 52246 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-02 Benjamin Darbro darbrob@gmail.com Iowa City Johnson Iowa Evangeline Kadera Denise Kandel Signed (1) The corporation rejects the employers’ liability coverage. Nicole Keck niccikeckllc@gmail.com Managing Member/Owner/President Iowa City Johnson Iowa Evangeline Kadera Denise Kandel Signed
530 2022-09-02 13:17 Anonymous (not verified) 173.20.146.6 Nicci Keck LLC 1107 Pheasant Valley St, Iowa City, IA 52246 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-02 Nicole Keck niccikeckllc@gmail.com Iowa City Johnson Iowa Evangeline Kadera Denise Kandel Signed (1) The corporation rejects the employers’ liability coverage. Nicole Keck niccikeckllc@gmail.com Managing Member/Owner/President Iowa City Johnson Iowa Evangeline Kadera Denise Kandel Signed
529 2022-09-01 13:53 Anonymous (not verified) 72.131.73.148 Sozo Companies, Inc. 23751 Hoover Road, Warren MI 48089 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-01 Aaron Rasty arasty@sozocompanies.com Austin Travis Texas Robert Davis Paul Huth Signed (1) The corporation rejects the employers’ liability coverage. Aaron Rasty arasty@sozocompanies.com President Austin Travis Texas Robert Davis Paul Huth Signed
528 2022-08-22 15:57 Anonymous (not verified) 75.146.219.201 James F. Valentine 300 Thomas Avenue, Bldg 401, Williamstown, NJ 08094 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-08-22 James F. Valentine jvalentine@valentineassoc.com Williamstown Gloucester New Jersey Kim Vona Dawn Souder Signed (1) The corporation rejects the employers’ liability coverage. James F. Valentine jvalentine@valentineassoc.com Owner Williamstown Gloucester New Jersey Kim Vona Dawn Souder Signed
527 2022-08-18 12:44 Anonymous (not verified) 75.146.219.201 James F. Valentine, Inc. 300 Thomas Avenue, Bldg 401, Williamstown, NJ 08094 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-08-18 James F. Valentine jvalentine@valentineassoc.com Williamstown Gloucester New Jersey Kim Vona Dawn Souder Signed (1) The corporation rejects the employers’ liability coverage. James F Valentine jvalentine@valentineassoc.com Owner Williamstown Gloucester New Jersey Kim Vona Dawn Souder Signed
526 2022-08-17 11:16 Anonymous (not verified) 173.27.233.86 Bradens Roofing and Construction Llc 2450 Hart Avenue I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-08-17 Arsenio Vargas Velazquez avargas409@gmail.com Des Moines polk Iowa Julissa Dionicio Jennifer Dionicio Signed (1) The corporation rejects the employers’ liability coverage. Arsenio Vargas Velazquez avargas409@gmail.com owner Des Moines Polk Iowa Julissa Dionicio Jennifer Dionicio Signed
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
524 2022-08-08 17:13 Anonymous (not verified) 50.82.182.101 Top Dog Tile Installation 8403 Brighton Court 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. 2022-08-08 Philip McCurdy tiletopdog@aol.com Cedar Rapids Linn IA Joshua Walter Schumacher Jeffrey Gerard Tilkes Signed (1) The corporation rejects the employers’ liability coverage. Philip McCurdy tiletopdog@aol.com Owner Cedar Rapids Linn IA Joshua Walter Schumacher Jeff Gerard Tilkes Signed
523 2022-07-29 10:25 Anonymous (not verified) 174.235.192.89 Jayden leinen 5176 ne 88th st altoona 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. 2022-07-29 Jayden leinen jman.legend@outlook.com Altoona Polk Iowa Kaden Barton Noah Penn Signed (1) The corporation rejects the employers’ liability coverage. Jayden Leinen jman.legend@outlook.con President Altoona Polk Iowa Kaden Barton Noah Penn Signed
522 2022-07-27 21:58 Anonymous (not verified) 173.25.135.5 Kokemiller construction 5995 Martin drive I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-27 Jessie james kokemiller jkokemo3@gmail.com Pleasant Hill Polk Ia Jonathon Hays Demi Muchmore Signed (1) The corporation rejects the employers’ liability coverage. Jessie James kokemiller jkokemo3@gmail.com President Pleasant Hill Polk Ia Jonathon Hays Demi Muchmore 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
520 2022-07-23 14:19 Anonymous (not verified) 69.57.205.10 Marquis Aviation, Inc 845 E. Redwood Circle I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-23 Robert Wescott Cantrell marquisaviationinc@yahoo.com Hanford Kings CA Shirley J. Loney Joel L. Meyer Signed (1) The corporation rejects the employers’ liability coverage. Robert W. Cantrell marquisaviationinc@yahoo.com Secretary Hanford Kings CA Shirley J. Loney Joel L. Meyer Signed
519 2022-07-22 13:55 Anonymous (not verified) 162.253.44.28 Seeger Truck Trailer Repair, Inc. 1125 66th AVE 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. 2022-08-01 Eldora Seegers royalwsilverII@gmail.com Cedar Rapids Linn Iowa John Seegers Julie Jones Signed (1) The corporation rejects the employers’ liability coverage. Eldora Seergers royalwsilverII@gmail.com Officer Cedar Rapids Linn Iowa John Seegers Julie Jones Signed
518 2022-07-21 10:58 Anonymous (not verified) 75.162.31.164 Bengard Roofing LLC 1927 Wethersfield Dr, Norwalk, IA 50211 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-21 Brandon Bengard bj@bengardroofing.com Norwalk Warren IA Rebecca Bengard Juhl Bengard Signed (1) The corporation rejects the employers’ liability coverage. Brandon Bengard bj@bengardroofing.com Owner Norwalk Warren IA Becky Bengard Juhl Bengard Signed
517 2022-07-19 15:43 Anonymous (not verified) 66.207.21.24 Frank Iliff 1424 B Houser Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-22 Frank Iliff rtmuscatine@gmail.com Muscatine IA United States Dewayne Hopkins James R. Bell Signed (1) The corporation rejects the employers’ liability coverage. Frank Iliff rtmuscatine@gmail.com Executive Director Muscatine IA United States Dewayne Hopkins James R. Bell Signed
516 2022-07-19 15:43 Anonymous (not verified) 66.207.21.24 Frank Iliff 1424 B Houser Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-22 Frank Iliff rtmuscatine@gmail.com Muscatine IA United States Dewayne Hopkins James R. Bell Signed (1) The corporation rejects the employers’ liability coverage. Frank Iliff rtmuscatine@gmail.com Executive Director Muscatine IA United States Dewayne Hopkins James R. Bell Signed
515 2022-07-19 10:06 Anonymous (not verified) 184.80.177.137 Mom Clean, LLC 4 East 3rd Street - Earlville, IA 52041 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-18 Morgan Lahr dparsons@english-insurance.com Dyersville Delaware IA Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com self Dyersville Dubuque IA Derrick Parsons Joyce Heims Signed
514 2022-07-15 11:51 Anonymous (not verified) 50.80.230.95 CRV, Inc 1607 LaPorte Rd Waterloo, IA 50702 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-15 Brett Allyn Corpman priorityone@thewebunwired.com Waterloo Black Hawk Iowa John W Vinton Stephen A Brustkern Signed (1) The corporation rejects the employers’ liability coverage. Brett Allyn Corpman priorityone@thewebunwired.com Officer Waterloo Black Hawk IA John W Vinton Stephen A Brustkern Signed
513 2022-07-15 11:49 Anonymous (not verified) 50.80.230.95 CRV, Inc 1607 LaPorte Rd Waterloo, IA 50702 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-15 Matthew Jason Corpman priorityone@thewebunwired.com Dysart Tama/Benton Iowa John W Vinton Stephen A Brustkern Signed (1) The corporation rejects the employers’ liability coverage. Matthew Jason Corpman priorityone@thewebunwired.com Officer Dysart Tama/Benton IA John W Vinton Stephen A Brustkern Signed
512 2022-07-15 11:45 Anonymous (not verified) 50.80.230.95 CRV, Inc 1607 LaPorte Rd Waterloo, IA 50702 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-15 Maureen Louise Corpman priorityone@thewebunwired.com Cedar Falls Black Hawk IA John W Vinton Stephen A Brustkern Signed (1) The corporation rejects the employers’ liability coverage. Maureen Louise Corpman priorityone@thewebunwired.com Officer Cedar Falls Black Hawk IA John W Vinton Stephen A Brustkern Signed
511 2022-07-15 11:41 Anonymous (not verified) 50.80.230.95 CRV, INC. 1607 LaPorte Rd Waterloo, IA 50702 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-15 Leonard Wayne Corpman priorityone@thewebunwired.com Cedar Falls Black Hawk IA John W Vinton Stephen A Brustkern Signed (1) The corporation rejects the employers’ liability coverage. Leonard Wayne Corpman priorityone@thewebunwired.com Officer Cedar Falls Black Hawk IA John W Vinton Stephen A Brustkern 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
509 2022-07-05 13:51 Anonymous (not verified) 96.31.7.128 KROESE CONSTRUSTION INC. 822 7TH 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. 2022-06-06 DAVID A KROESE dkkroese@hotmail.com Hull Sioux Iowa MATTHEW ROETMAN JOYCE VANDER WELL Signed (1) The corporation rejects the employers’ liability coverage. SCOTT I KROESE scottkroese@hotmail.com vice president HULL SIOUX IOWA MATTHEW ROETMAN JOYCE VANDER WELL Signed
508 2022-07-04 18:49 Anonymous (not verified) 107.77.210.228 RM Construction, Rafael Marquez DBA 6520 SE 5th ST, Apt 4, 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. 2022-07-04 Rafael Marquez marquezrafael1@outlook.com 6520 SE 5th ST, Apt 4, Des Moines IA, 50315 Polk IOWA Richard Yanez Jesus Perez Signed (1) The corporation rejects the employers’ liability coverage. Rafael Marquez marquezrafael1@outlook.com owner Des Moines Polk IOWA Richard Yanez Jesus Perez 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
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
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
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
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
502 2022-06-24 12:15 Anonymous (not verified) 173.31.148.43 HISTORIC ARNOLDS PARK INC 37 LAKE ST ARNOLDS PARK, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-24 GARY RAY GARYJRAY70@GMAIL.COM SPIRIT LAKE DICKINSON IOWA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The corporation rejects the employers’ liability coverage. JON PAUSLEY JON@ARNOLDSPARK.COM CEO MILFORD DICKINSON IOWA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
501 2022-06-24 12:10 Anonymous (not verified) 173.31.148.43 HISTORIC ARNOLDS PARK INC 37 LAKE ST ARNOLDS PARK, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2022-06-24 JON PAUSLEY JON@ARNOLDSPARK.COM MILFORD DICKINSON IOWA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (2) The corporation declines to reject the employers’ liability coverage. JON PAUSLEY JON@ARNOLDSPARK.COM CEO MILFORD DICKINSON IOWA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
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
499 2022-06-22 03:40 Anonymous (not verified) 64.251.168.116 VALBURG AERIAL SPRAYING INC. 27656 SD Hwy 44 WHITE RIVER SD 57579 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-19 Dan A Valburg agflyer620@gwtc.net White River SD SD LANDON HOSSLE JOSH HICKS Signed (1) The corporation rejects the employers’ liability coverage. Dan A Valburg agflyer620@gwtc.net PRESIDENT White River SD SD LANDON HOSSLE JOSH HICKS Signed
498 2022-06-17 08:45 Anonymous (not verified) 64.5.79.180 The Sign Shed & Graphics LLC 529 Erie St, PO Box 252 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-26 Brent Ulrich signshed@yahoo.com Storm Lake IA United States Zach Ruroden Ryan Young Signed (1) The corporation rejects the employers’ liability coverage. Brent Ulrich signshed@yahoo.com CEO Storm Lake IA United States Zach Ruroden Ryan Young Signed
497 2022-06-16 11:09 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. 2022-06-01 WALLACE KENNEDY wkennedy@babcockservices.com Richland Benton Washington Angie Jimenez Karen Patterson Signed (1) The corporation rejects the employers’ liability coverage. Carmen Clyde cclyde@babcockservices.com Secretary Kennewick Benton Washington Angie Jimenez Karen Patterson Signed
496 2022-06-15 10:11 Anonymous (not verified) 50.81.253.108 WALLICK FAMILY TRUCKING INC 2374 UNION AVE, VILLISCA, IA 50864 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-15 JUSTIN WALLICK SCRALL@PARTNERSINS.COM VILLISCA MONTGOMERY IOWA JAMES S CRALL RICHARD D CRALL Signed (1) The corporation rejects the employers’ liability coverage. JUSTIN WALLICK SCRALL@PARTNERSINS.COM PRESIDENT VILLISCA MONTGOMERY IOWA JAMES S CRALL RICHARD D CRALL Signed
495 2022-06-08 13:07 Anonymous (not verified) 173.31.148.43 OKOBOJI PERFORMING ARTS 97 WOODLIN DR MILFORD, IA 51351 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-08 DREW DUNCAN DREW@OKOBOJIPERFORMINGARTS.COM LINCOLN LANCASTER NE JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The corporation rejects the employers’ liability coverage. DREW DUNCAN DREW@OKOBOJIPERFORMINGARTS.COM SELF LINCOLN LANCASTER NE JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
494 2022-06-08 13:04 Anonymous (not verified) 173.31.148.43 OKOBOJI PERFORMING ARTS 97 WOODLIN DR MILFORD, IA 51351 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-08 JOHN MOORE JOHN@OKOBOJIPERFORMINGARTS.COM MINNEAPOLIS HENNEPIN MN JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The corporation rejects the employers’ liability coverage. JOHN MOORE JOHN@OKOBOJIPERFORMINGARTS.COM SELF MINNEAPOLIS HENNEPIN MN JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
493 2022-06-08 13:00 Anonymous (not verified) 173.31.148.43 OKOBOJI PERFORMING ARTS 97 WOODLIN DR MILFORD, IA 51351 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-06 JESSICA SCHABLE JESS@OKOBOJIPERFORMINGARTS.COM MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The corporation rejects the employers’ liability coverage. JESSICA SCHABLE JESS@OKOBOJIPERFORMINGARTS.COM SELF MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN 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
491 2022-06-06 09:32 Anonymous (not verified) 24.118.76.144 Minnesota Restoration Contractors Inc. DBA MNRC 12252 Nicollet Ave Burnsville, MN 55337 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-06 Daniel Lewis Lillestol info@mnrcinc.com Wayzata MN United States Karina Bazhenova MICHELLE LILLESTOL Signed (1) The corporation rejects the employers’ liability coverage. Daniel Lewis Lillestol info@mnrcinc.com CEO Wayzata Hennnepin MN Karina Bazhenova MICHELLE LILLESTOL Signed
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
489 2022-06-02 13:09 Anonymous (not verified) 96.31.21.223 Lamfers Farm Inc 2161 Jackson Ave George IA 51237 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-23 Charnele Lamfers rclamfers@gmail.com George Lyon Iowa Shannon Monson Teresa Hoogendoorn Signed (1) The corporation rejects the employers’ liability coverage. Roger Lamfers rclamfers@gmail.com President George Lyon Iowa Shannon Monson Teresa Hoogendoorn Signed
488 2022-06-02 13:06 Anonymous (not verified) 96.31.21.223 Lamfers Farm Inc 2161 Jackson Ave George IA 51237 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-23 Roger Lamfers rclamfers@gmail.com George Lyon Iowa Shannon Monson Teresa Hoogendoorn Signed (1) The corporation rejects the employers’ liability coverage. Roger Lamfers rclamfers@gmail.com President George Lyon Iowa Shannon Monson Teresa Hoogendoorn Signed
487 2022-06-02 08:36 Anonymous (not verified) 173.18.193.51 Wever Fire Association 1692 354th Avenue, Wever, Iowa 52658 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-25 Jacob Denning judy@fullenkampins.com Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Jacob Denning judy@fullenkampins.com Board Member Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed
486 2022-06-02 08:34 Anonymous (not verified) 173.18.193.51 Wever Fire Association 1692 354th Avenue, Wever, Iowa 52658 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-24 Craig Pieper judy@fullenkampins.com Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Craig Pieper Judy@fullenkampins.com Vice President Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed
485 2022-06-02 08:33 Anonymous (not verified) 173.18.193.51 Wever Fire Association 1692 354th Avenue, Wever, Iowa 52658 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-24 Hugh Vandgriff judy@fullenkampins.com Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Hugh Vandegriff Judy@fullenkampins.com board member Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed
484 2022-06-02 08:31 Anonymous (not verified) 173.18.193.51 Wever Fire Association 1692 354th Avenue, Wever, Iowa 52658 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-24 Gregory Liddle judy@fullenkampins.com Wever Lee Iowa Chris Fullenkamp judy moeller Signed (1) The corporation rejects the employers’ liability coverage. Gregory Liddle judy@fullenkampins.com President Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed
483 2022-06-02 08:28 Anonymous (not verified) 173.18.193.51 Wever Fire Association 1692 354th Avenue, Wever, Iowa 52658 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-24 Deb Sylvester judy@fullenkampins.com Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Deb Sylvester judy@fullenkampins.com Secretary / Treasurer Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed
482 2022-06-02 08:25 Anonymous (not verified) 173.18.193.51 Wever Fire Association 1692 354th Avenue, Wever, Iowa 52658 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-24 Bill Brookhiser judy@fullenkampins.com Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Bill Brookhiser judy@fullenkampins.com Board Member Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed
481 2022-05-30 11:42 Anonymous (not verified) 134.215.6.237 Access Property Management Corp DBA Wine & Spirits 510 E Carrington Ln, Appleton, WI 54913 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-30 Thomas J Ricklefs tjrick@yahoo.com Appleton Outagamie WI Jeff Fonferek Melissa Fonferek Signed (1) The corporation rejects the employers’ liability coverage. Lisa M Ricklefs lisarick19@yahoo.com VP Appleton Outagamie WI Jeff Fonferek Melissa Fonferek Signed
480 2022-05-30 11:37 Anonymous (not verified) 134.215.6.237 Access Property Management Corp DBA Wine & Spirits 510 E Carrington Ln, Appleton, WI 54913 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-30 Lisa M Ricklefs lisarick19@yahoo.com Appleton Outagamie WI Jeff Fonferek Melissa Fonferek Signed (1) The corporation rejects the employers’ liability coverage. Thomas Ricklefs tjrick@yahoo.com President Appleton Outagamie WI Jeff Fonferek Melissa Fonferak Signed
479 2022-05-26 14:05 Anonymous (not verified) 71.28.218.225 TRAER MUSEUM 514 2ND ST. TRAER, IA 50675 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-26 Carol Boyce carolwoodboyce@gmail.com Dysart Tama IOWA EDWARD HOEG KIM DAHMS Signed (1) The corporation rejects the employers’ liability coverage. CAROL BOYCE carolwoodboyce@gmail.com VICE PRESIDENT Dysart Tama IOWA ED HOEG KIM DAHMS Signed
478 2022-05-24 13:16 Anonymous (not verified) 63.146.149.12 EBN CONSTRUCTION LLC 314 NE 5TH 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. (1) I reject the employers’ liability coverage. 2022-05-24 Juan J Perez Munoz ebnconstruction@icloud.com Des Moines Polk Iowa Jaime Leiva Kevin Pham Signed (1) The corporation rejects the employers’ liability coverage. Juan J Perez Munoz ebnconstruction@icloud.com Owner Des MOines Polk Iowa Jaime Leiva Kevin Pham Signed
477 2022-05-19 11:49 Anonymous (not verified) 172.86.13.54 BOLT HOLDINGS Inc. and Holt Precision dba Holt Bladeworks and Holt Kinetic Solutions 3230 N. Center Point Rd Unit 204, Marion, IA 52302 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-19 Ben Congleton Ben@holtkineticsolutions.com Cedar Rapids Linn Iowa Lisa Gleason Angey Holt Signed (1) The corporation rejects the employers’ liability coverage. Lisa Gleason Lisa@holtkineticsolutions.com General Manager Marion Linn Iowa Lisa Gleason Danielle Congleton Signed
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
475 2022-05-19 10:11 Anonymous (not verified) 172.86.13.54 BOLT HOLDINGS Inc. and Holt Precision dba Holt Bladeworks and Holt Kinetic Solutions 3230 N. Center Point Rd Unit 204, Marion, IA 52302 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-19 Angey Holt Angey@Holtkineticsolutions.com Robins Linn Iowa Lisa Gleason Danielle Congleton Signed (1) The corporation rejects the employers’ liability coverage. Lisa Gleason Lisa@holtkineticsolutions.com General Manager Marion Linn Iowa Danielle Congleton Joe Holt Signed
474 2022-05-16 16:25 Anonymous (not verified) 208.126.193.1 Gentle Bend Inc. 1075 120th Street, Wellman, Iowa 52356 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-16 Georgia Gent ggent83@gmail.com Wellman Washington Iowa Jeff Spenner Shawn Powell Signed (1) The corporation rejects the employers’ liability coverage. Georgia Gent ggent83@gmail.com owner Wellman Washington Iowa Jeff Spenner Shawn Powell Signed
473 2022-05-16 14:20 Anonymous (not verified) 167.142.231.34 Trust Builders, LLC 1055 Jordan Creek Parkway, Suite 200, West Des Moines, IA 50226 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-16 Christopher Dean Petersen chrispetersen@trustbuildersiowa.com Polk City Polk Iowa Curtis William Blake Joseph Duane Meints Signed (1) The corporation rejects the employers’ liability coverage. Christopher Dean Petersen chrispetersen@trustbuildersiowa.com Owner Polk City Polk Iowa Curtis William Blake Joseph Duane Meints Signed
472 2022-05-13 11:19 Anonymous (not verified) 69.18.19.139 BES, Inc. 1615 E Washington St, Mt Pleasant, IA 52641 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-13 Todd Baldridge todd.baldridge@beswatersolutions.com West Branch Cedar Iowa Nicholas Baldridge Owen Baldridge Signed (1) The corporation rejects the employers’ liability coverage. Randy Seberg randy.seberg@beswatersolutions.com Managing Director Mt Pleasant Henry IA John Rodewald Matt Mowery Signed
471 2022-05-13 10:08 Anonymous (not verified) 104.166.245.37 Juan Ramiro Rivas Perez 6211 SW 5th Street. Des Moines IA 50315 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-02 Juan Ramiro Rivas Perez cecyperezv1982@icloud.com Des Moines Polk Iowa Carmen Perez Oscar Ramirez Signed (1) The corporation rejects the employers’ liability coverage. Juan Ramiro Rivas Perez cecyperezv1982@icloud.com Secretary Des Moines Polk Iowa Carmen Perez Oscar Ramirez Signed
470 2022-05-12 14:28 Anonymous (not verified) 173.184.134.123 Bryce Hoffert LLC 1802 Lake Street Emmetsburg Iowa 50536 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-12 Bryce C Hoffert brycehoffertllc@gmail.com Emmetsburg Pala Alto Iowa Ray Hoffert Shelbie Hurdle Signed (1) The corporation rejects the employers’ liability coverage. Bryce Hoffert brycehoffertllc@gmail.com member Emmetsburg Palo Alto Iowa Ray Hoffert Shelbie Hurdle Signed
469 2022-05-12 11:38 Anonymous (not verified) 173.23.25.243 RS- Remodelers 2863 104th St Urbandale IA 50322 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2022-05-12 Stephen Dillon clearchoicedesmoinesia@gmail.com Waukee Dallas IA Rob Nevitt Jordan Nevitt Signed (2) The corporation declines to reject the employers’ liability coverage. Stephen clearchoicedesmoinesia@gmail.com Owner Waukee Dallas IA Rob Nevitt Jordan Nevitt Signed
468 2022-05-12 11:33 Anonymous (not verified) 173.23.25.243 RS Remodelers 2863 104th St Urbandale IA 50322 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2022-05-12 Robert Nevitt rwnevitt@yahoo.com PERRY DALLAS IA Steve Dillon Jordan Nevitt Signed (2) The corporation declines to reject the employers’ liability coverage. Robert Nevitt clearchoicedesmoinesia@gmail.com Owner Urbandale Dallas ia Steve Dillon Jordan Nevitt Signed
467 2022-05-09 10:54 Anonymous (not verified) 209.180.36.109 Sani Enterprise 101 Ashworth Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-09 Safet Derguti safetigo@hotmail.com Des Moines Polk Iowa Andrew Swanson Sandro Tadic Signed (1) The corporation rejects the employers’ liability coverage. Andrew Swanson sanienterprise14@gmail.com Director of Operations Granger Dallas Iowa Andrew Swanson Sandro Tadic Signed
466 2022-05-09 10:52 Anonymous (not verified) 209.180.36.109 Sani Enterprise 101 Ashworth Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-09 Claude Riley Rileybuddy58@gmail.com Johnston Polk Iowa Andrew Swanson Claude Riley Signed (1) The corporation rejects the employers’ liability coverage. Andrew Swanson sanienterprise14@gmail.com Director of Operations Granger Dallas Iowa Andrew Swanson Sandro Tadic Signed
465 2022-05-08 19:08 Anonymous (not verified) 173.27.224.202 Vail Foundations 1508 West Clinton Ave 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. 2022-05-08 Cory Vail vailfoundations@gmail.com Indianola Warren Iowa Monica Vaik James Vail Signed (1) The corporation rejects the employers’ liability coverage. Cory James Vail vailfoundations@gmail.com President Indianola Warren Iowa Monica Vail James Vail Signed
464 2022-05-06 10:15 Anonymous (not verified) 172.86.44.178 Cornhill Express LLC 6472 40th 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. 2022-05-06 Jamie Fettkether sales@cherepair.com Aurora Buchanan Iowa Ben Hogan Ryan Peyton Signed (1) The corporation rejects the employers’ liability coverage. Jamie Fettkether sales@cherepair.com Owner Aurora Buchanan Iowa Ben Hogan Ryan Peyton Signed
463 2022-05-02 16:02 Anonymous (not verified) 71.39.227.238 IN SEASON LAWN CARE LLC 32841 HOMESTEAD DR, GRANGER, IA 50109 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-02 CHEYENNE COVER inseason98@gmail.com Granger Dallas Iowa Abbey Luellen Steve Phillips Signed (1) The corporation rejects the employers’ liability coverage. CHEYENNE Cover inseason98@gmail.com Owner Granger Dallas Iowa Abbey Luellen Steve Phillips Signed
462 2022-05-02 16:01 Anonymous (not verified) 71.39.227.238 IN SEASON LAWN CARE LLC 32841 HOMESTEAD DR, GRANGER, IA 50109 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-02 JOSEPH CRAIG COVER inseason98@gmail.com Granger Dallas Iowa Abbey Luellen Steve Phillips Signed (1) The corporation rejects the employers’ liability coverage. Joseph Craig Cover inseason98@gmail.com Owner Granger Dallas Iowa Abbey Luellen Steve Phillips Signed
461 2022-05-02 11:08 Anonymous (not verified) 192.119.212.86 Iceberg Enterprises LLC 101 E. 1st street Arthur IA 51431 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-02 Jesse Bergman jk_montana@yahoo.com arthur Iowa United States Maren Smith Darren Smith Signed (1) The corporation rejects the employers’ liability coverage. Katherine Bergman jk_montana@yahoo.com Owner Arthur IOWA United States Susan Bergman Jesse Bergman Signed
460 2022-05-02 10:00 Anonymous (not verified) 73.9.3.194 ERLIN AVILA INC 1940 N GREEN LN APT 2A PALATINE IL 60074 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-02 ERLIN AVILA INC dianalcandelaria@aol.com PALATINE COOK IL DIANA CANCELARIA DALILA VILLEGAS Signed (1) The corporation rejects the employers’ liability coverage. ERLIN AVILA TORREZ dianalcandelaria@aol.com PRESIDENT PALATINE Illinois United States Diana L Candelaria DALILA VILLEGAS 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
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
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
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
455 2022-04-27 14:04 Anonymous (not verified) 184.80.177.137 Classic Custom Cabinets, Inc 31931 Bries Drive , Dyersville, IA 52040 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-27 Mike Then jheims@english-insurance.com Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Joyce Heims jheims@english-insurance.com agent Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed
454 2022-04-26 14:03 Anonymous (not verified) 216.106.225.224 Kevin Knapp 2227 120th 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. 2022-04-26 Nathan Glenn Knapp knapptimedairy@gmail.com larchwood lyon ia Eric TeGrootenhuis Lisa Faber Signed (1) The corporation rejects the employers’ liability coverage. Kevin Knapp knapptimedairy@gmail.com owner Larchwood Iowa United States Eric TeGrootenhuis Lisa Faber Signed
453 2022-04-22 16:07 Anonymous (not verified) 75.63.172.134 Tempus Builders, Inc. 4331 Valley Ridge 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. 2022-04-22 Jennifer Cooper scott@tempusbuilders.com Dallas TX United States Phil Sheumaker Cristen Cooper Signed (1) The corporation rejects the employers’ liability coverage. Scott Cooper scott@tempusbuilders.com President Dallas TX United States James Buckley Phil Sheumaker Signed
452 2022-04-22 16:06 Anonymous (not verified) 75.63.172.134 Tempus Builders, Inc. 4331 Valley Ridge 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. 2022-04-22 Scott Cooper scott@tempusbuilders.com Dallas TX United States Phil Sheumaker Cristen Cooper Signed (1) The corporation rejects the employers’ liability coverage. Scott Cooper scott@tempusbuilders.com President Dallas TX United States James Buckley Phil Sheumaker Signed
451 2022-04-22 16:06 Anonymous (not verified) 75.63.172.134 Tempus Builders, Inc. 4331 Valley Ridge 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. 2022-04-22 Scott Cooper scott@tempusbuilders.com Dallas TX United States Phil Sheumaker Cristen Cooper Signed (1) The corporation rejects the employers’ liability coverage. Scott Cooper scott@tempusbuilders.com President Dallas TX United States James Buckley Phil Sheumaker 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
449 2022-04-19 21:09 Anonymous (not verified) 172.86.44.178 Holtkamp Transportation LLC 2282 Windmill Way, West Point, IA 52656 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-19 Les Holtkamp les@holtkamplogistics.com West Point Lee Iowa Ben Hogan Tina Holtkamp Signed (2) The corporation declines to reject the employers’ liability coverage. Ben Hogan ben@truserveins.com Insurance Agent Readlyn Bremer Iowa Jaci Hogan Nicole Barnes Signed
448 2022-04-19 15:15 Anonymous (not verified) 184.80.177.137 Andrew Lemke DBA: TAP Fabrication 27214 218th Street, Earlville, IA 52041 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-08 Andrew Lemke jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
447 2022-04-15 16:59 Anonymous (not verified) 166.181.87.86 STEVE MORRISON TRUCKING P.O. Box 66 Danville,IA 52623 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-15 Stephen D. Morrison sdmt13@gmail.com Danville Des Moines IA Ellie Miller Janice Helt Signed (1) The corporation rejects the employers’ liability coverage. Stephen Dwight Morrison sdmt13@gmail.com Owner Danville Des Moines IA Ellie Miller Janice Helt 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
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
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
443 2022-04-11 13:15 Anonymous (not verified) 75.162.175.12 Castro construction LLC 1712 carpenter av desmoines Iowa 50314 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-11 Carlos Alberto castro Alcántara castrodvxhd@gmail.com Estados Unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe padilla bonilla Signed (1) The corporation rejects the employers’ liability coverage. Carlos Alberto castro Alcántara castrodvxhd@gmail.com Owner Estados unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe Padilla Bonilla Signed
442 2022-04-11 13:15 Anonymous (not verified) 75.162.175.12 Castro construction LLC 1712 carpenter av desmoines Iowa 50314 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-11 Carlos Alberto castro Alcántara castrodvxhd@gmail.com Estados Unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe padilla bonilla Signed (1) The corporation rejects the employers’ liability coverage. Carlos Alberto castro Alcántara castrodvxhd@gmail.com Owner Estados unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe Padilla Bonilla Signed
441 2022-04-11 13:15 Anonymous (not verified) 75.162.175.12 Castro construction LLC 1712 carpenter av desmoines Iowa 50314 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-11 Carlos Alberto castro Alcántara castrodvxhd@gmail.com Estados Unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe padilla bonilla Signed (1) The corporation rejects the employers’ liability coverage. Carlos Alberto castro Alcántara castrodvxhd@gmail.com Owner Estados unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe Padilla Bonilla Signed
440 2022-03-29 20:05 Anonymous (not verified) 174.215.228.20 Navarro construction 2825 SE 14th St lot #6 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or 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 Enrique Navarro enriquenavarro887@gmail.com Des Moines Polk IA Alondra Navarro René Navarro Signed (1) The corporation rejects the employers’ liability coverage. Enrique Navarro enriquenavarro884@gmail.com Owner Des moines Polk IA Alondra Navarro René Navarro 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
438 2022-03-29 16:28 Anonymous (not verified) 209.180.36.109 Sani Enterprise 101 Ashworth Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-29 Azmir Alic ale_boss00@hotmail.com Urbandale polk iowa Azmir Alic Andrew Swanson Signed (1) The corporation rejects the employers’ liability coverage. Andrew Swanson sanienterprise14@gmail.com Director of Operations Granger Dallas Iowa Andrew Swanson Sandro Tadic Signed
437 2022-03-29 14:03 Anonymous (not verified) 209.180.36.109 Sani Enterprise 101 Ashworth Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-29 Mersad Bosnic mersadbosnic@yahoo.com Urbandale Polk Iowa Mersad Bosnic Andy Swanson Signed (1) The corporation rejects the employers’ liability coverage. Andy Swanson sanienterprise14@gmail.com Director of Operations Granger Dallas Iowa Andrew Swanson Sandro Tadic Signed
436 2022-03-29 11:07 Anonymous (not verified) 184.80.177.137 Adam Sheppard 22194 260th St - Delhi, Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-24 Adam Sheppard jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Adam Sheppard jheims@english-insurance.com agent Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
435 2022-03-28 07:14 Anonymous (not verified) 75.162.66.125 Jenkins Electric LLC 304 E North St. Prairie City, IA I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-28 Colten Jenkins colten@jenkins-electric.com Prairie City Jasper Iowa Kristin Jenkins David Jennings Signed (1) The corporation rejects the employers’ liability coverage. Colten Jenkins colten@jenkins-electric.com Owner Prairie City Jasper Iowa Kristin Jenkins David Jennings Signed
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
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
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
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
430 2022-03-24 14:47 Anonymous (not verified) 173.30.76.116 Franky's Construction 1419 Acacia Dr 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. 2022-03-24 Franky Ackley fackley1981@gmail.com Cedar Rapids Linn IA Rick DeNeve Kailee Carstensen Signed (1) The corporation rejects the employers’ liability coverage. Franky Ackley fackley1981@gmail.com Owner Cedar Rapids Linn IA Rick DeNeve Kailee Carstensen Signed
429 2022-03-24 13:37 Anonymous (not verified) 174.255.1.155 Franky's Construction 1419 Acacia Dr 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. 2022-03-24 Frank Ackley fackley1981@gmail.com Cedar Rapids Linn IA Rick Deneve Kailee Carstensen Signed (1) The corporation rejects the employers’ liability coverage. Franky Ackley fackley1981@gmail.com Owner Cesar Rapids Linn IA Rick DeNeve Kailee Carstensen 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
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
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
425 2022-03-16 07:57 Anonymous (not verified) 173.29.149.199 Schult Industries Inc PO Box 165 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. 2022-03-17 MIKE SCHULT mschult10@gmail.com CLINTON Clinton Iowa Rhonda Schult Lance VanDeest Signed (1) The corporation rejects the employers’ liability coverage. MIKE SCHULT mschult10@gmail.com Owner CLINTON Clinton Iowa Rhonda Schult Lance VanDeest Signed
424 2022-03-11 15:36 Anonymous (not verified) 69.63.16.2 BR Flynn Co Inc 16756 Corey Daniel Ct, Dubuque, IA 52001 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-11 Bruce R Flynn br.flynn4@gmail.com Dubuque Dubuque Iowa Rick Meyer Dyan Kriener Signed (1) The corporation rejects the employers’ liability coverage. Bruce R Flynn br.flynn4@gmail.com President Dubuque Dubuque IA Rick Meyer Dyan Kriener Signed
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
422 2022-03-08 08:56 Anonymous (not verified) 98.16.51.166 Trility Group Holdings, Inc. 14001 University Avenue, Suite 300, Clive IA 50125 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-08 Matthew D Edwards matthew@trility.io New Virginia Warren Iowa Devin Boyer Kyle Woiwood Signed (1) The corporation rejects the employers’ liability coverage. Matthew D Edwards matthew@trility.io President New Virginia Warren Iowa Devin Boyer Kyle Woiwood Signed
421 2022-03-07 17:14 Anonymous (not verified) 174.215.244.140 MJ Kunkel Trucking, LLC 403 N Ash 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. 2022-03-07 Michael John Kunkel mjkunkeltrucks@gmail.com Marcus IA United States Adam Bartels Karlee Ohrt Signed (1) The corporation rejects the employers’ liability coverage. Michael John Kunkel mikekunkel0361@gmail.com Self Marcus IA United States Adam Bartels Karlee Ohrt 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
419 2022-03-03 14:37 Anonymous (not verified) 68.13.47.145 Trility Group Holdings, Inc 14001 University Ave, Suite 300 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-03 James Brody Deren brody@trility.io Omaha Douglas Nebraska Devin Boyer Kyle Woiwood Signed (1) The corporation rejects the employers’ liability coverage. James Brody Deren brody@trility.io Secretary Omaha Douglas Nebraska Devin Boyer Kyle Woiwood Signed
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
417 2022-03-03 13:20 Anonymous (not verified) 67.41.107.230 Trility Group Holdings, Inc. 14001 University Ave, Suite 300, Clive, IA 50125 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-03 Brenton David Rothchild brenton@trility.io Indianola Warren IA Devin Boyer Kyle Woiwood Signed (1) The corporation rejects the employers’ liability coverage. Brenton David Rothchild brenton@trility.io Treasurer Indianola Warren IA Devon Boyer Kyle Woiwood Signed
416 2022-02-25 08:15 Anonymous (not verified) 70.100.125.106 Coachlight Condominium Owners Association 714 14th Ave N, Fort Dodge, IA 50501 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-25 Alan Wooters shirise@wtcta.net Fort Dodge Webster IA Randy Ranthum Paul Templemeyer Signed (1) The corporation rejects the employers’ liability coverage. Alan Wooters shirise@wtcta.net President Fort Dodge Webster IA Jackie Jacobs Paula Templemeyer Signed
415 2022-02-25 08:13 Anonymous (not verified) 70.100.125.106 Coachlight Condominium Owners Association 714 14th Ave N, Fort Dodge, IA 50501 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-25 Joyce Hanson jmhanson820@outlook.com Fort Dodge Webster IA Randy Ranthum Jackie Jacobs Signed (1) The corporation rejects the employers’ liability coverage. Alan Wooters shirise@wtcta.net President Fort Dodge Webster IA Jackie Jacobs Paula Templemeyer Signed
414 2022-02-25 08:10 Anonymous (not verified) 70.100.125.106 Coachlight Condominium Owners Association 714 14th Ave N, Fort Dodge, IA 50501 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-25 Lowell W Cornwell lwcornwell@frontiernet.net Fort Dodge Webster IA Randy Ranthum Paul Templemeyer Signed (1) The corporation rejects the employers’ liability coverage. Alan Wooters shirise@wtcta.net President Fort Dodge Webster IA Jackie Jacobs Paula Templemeyer Signed
413 2022-02-23 16:31 Anonymous (not verified) 184.80.177.137 T-Rex Hospitality LLC, DBA FUSE 120 Twin Steeples Circle, Dyersville Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-23 Tara Rahe jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
412 2022-02-23 15:42 Anonymous (not verified) 208.126.112.220 Bergmann Bros. Excavating & Trucking PO Box G, Frederika, IA 50631 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-23 Kenny A. Bergmann kennb@butler-bremer.com Frederika Bremer Iowa Ronald A. Bergmann Tad M. Chapin Signed (1) The corporation rejects the employers’ liability coverage. Kenny A. Bergmann kennb@butler-bremer.com self Frederika Bremer Iowa Ronald A. bergmann Tad M. Chapin Signed
411 2022-02-23 15:06 Anonymous (not verified) 173.19.163.201 DK Pluming and Excavating 12439 S 60TH AVE W I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-23 JAMES DONAHOO DKPIPELLC@GMAIL.COM PRAIRIE CITY Jasper IA David Graber Matt Bengston Signed (1) The corporation rejects the employers’ liability coverage. James Donahoo DKPIPELLC@GMAIL.COM Owner PRAIRIE CITY Jasper IA David Graber Matt Bengston 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
409 2022-02-18 11:32 Anonymous (not verified) 173.31.148.43 PACKEBUSH SPRINKLER SERVICE INC 1960 170TH AVE MILFORD, IA 51351 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-09 KARA PACKEBUSH RKPACKEBUSH@GMAIL.COM MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The corporation rejects the employers’ liability coverage. KARA PACKEBUSH JOEL@WALKERINSURANCEIA.COM VICE PRESIDENT MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
408 2022-02-18 11:30 Anonymous (not verified) 173.31.148.43 PACKEBUSH SPRINKLER SERVICE INC 1960 170TH AVE MILFORD, IA 51351 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-09 ROSS PACKEBUSH RKPACKEBUSH@GMAIL.COM MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The corporation rejects the employers’ liability coverage. ROSS PACKEBUSH joel@walkerinsuranceia.com PRESIDENT MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
407 2022-02-16 15:44 Anonymous (not verified) 173.18.126.91 Huff Construction LLC 1309 Business 30 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. 2022-02-16 Jason Huff jason@huff-construction.com Mount Vernon Linn Iowa Katie Huff Rick Deneve Signed (1) The corporation rejects the employers’ liability coverage. Jason Huff jason@huff-construction.com Owner Mount Vernon Linn Iowa Katie Huff Rick Deneve Signed
406 2022-02-15 17:30 Anonymous (not verified) 173.18.126.91 Huff Construction 1309 Business 30 sw Mount Vernon 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. 2022-02-15 Jason Huff jason@huff-construction.com Mount Vernon Linn Iowa Katie Huff Rick Deneve Signed (1) The corporation rejects the employers’ liability coverage. Jason Huff jason@huff-construction.com Owner Mount Vernon Linn Iowa Katie Huff Rick Deneve Signed
405 2022-02-14 10:36 Anonymous (not verified) 207.199.239.234 My Nest Greenhouse 1134-1600 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. 2022-02-14 Patti Bogler mynest@fmctc.com Harlan Iowa Iowa Hallie Carroll Katrina Shea Signed (1) The corporation rejects the employers’ liability coverage. Patti Bogler mynest@fmctc.com owner Harlan Iowa Iowa Hallie Lynn Carroll Katrina Mae Shea Signed
404 2022-02-13 12:50 Anonymous (not verified) 217.180.228.177 Premier Property Group LLC 8805 Chambery Blvd Ste 300 #217 Johnston, IA 50131 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-13 Cade Montgomery ppgiowallc@gmail.com Johnston Polk Iowa Cailey Montgomery Sara Saylor Signed (1) The corporation rejects the employers’ liability coverage. Cade Montgomery ppgiowallc@gmail.com Owner Johnston Polk Iowa Cailey Montgomery Sara Saylor Signed
403 2022-02-09 14:14 Anonymous (not verified) 108.59.100.21 T Js Fencing Inc 461 Hwy 76, Harpers Ferry IA 52146 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-13 Travis Johanningmeier tjfence@acegroup.cc Harpers Ferry Allamakee Iowa Jessica Kruse Jane M Regan Signed (1) The corporation rejects the employers’ liability coverage. Travis Johanningmeier tjfence@acegroup.cc President Harpers Ferry Allamakee Iowa Jessica Kruse Jane M Regan Signed
402 2022-02-09 09:46 Anonymous (not verified) 69.57.33.202 Toby K's Hideaway Inc. dba Toby K's Hideaway 1723 Mamie Eisenhower Ave, 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. 2022-02-09 Toby Kruse samanthapeck@boehmins.com Boone Boone Iowa Samantha Peck Hans Boehm Signed (1) The corporation rejects the employers’ liability coverage. Toby Kruse samanthapeck@boehmins.com Owner Boone Boone Iowa Samantha Peck Hans Boehm Signed
401 2022-02-08 11:16 Anonymous (not verified) 173.29.121.248 NW Bender LLC DBA Agent Clean 3229 E Ovid 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. 2022-02-07 Nikolas W Bender Nikolas@agentclean.com Des Moines Polk Iowa Stan Mohr Victor Flores Signed (1) The corporation rejects the employers’ liability coverage. Nikolas W Bender Nikolas@agentclean.com Self Des Moines Polk Iowa Stan Mohr Victor Flores Signed
400 2022-02-04 10:37 Anonymous (not verified) 173.16.199.106 Paradigm Construction 960 Pelican Drive – Polk City, IA 50226 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-04 MATTHEW HENDRICKSON matthendrickson88@gmail.com NORWALK IA United States Richard Green Sheldon Thompson Signed (1) The corporation rejects the employers’ liability coverage. Ryan Shabino ryan@prdgmconstruction.com Contractor 960 Pelican Drive – Polk City, IA 50226 Polk Iowa Richard Green Sheldon Thompson Signed
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
398 2022-02-01 18:50 Anonymous (not verified) 172.58.83.243 essential renovation LLC 516 e center st, freeport il I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-01 teodoro jimenez essentialrenovations.llc@gmail.com freeport stephenson il adam spear karly spear Signed (1) The corporation rejects the employers’ liability coverage. sandra cuatlatl essentialrenovations.llc@gmail.com owner freeport stephenson il adam spear karly spear Signed
397 2022-02-01 10:30 Anonymous (not verified) 159.242.43.24 Providence Casework PO Box 205 Rockwell, IA 50469 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or 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 Neal Keeling office@procaseworks.com Rockwell Cerro Gordo Iowa Josh Olson John Moran Signed (1) The corporation rejects the employers’ liability coverage. Neal Keeling office@procaseworks.com Owner Rockwell Cerro Gordo Iowa Josh Olson John Moran Signed
396 2022-02-01 10:03 Anonymous (not verified) 184.80.177.137 LKB Holdings, LLC P.O. box 313 - Monona, Ia 52159 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-29 Kandi Gillitzer jheims@english-insurance.com Monoa Clayton Iowa Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com self Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
395 2022-01-31 15:49 Anonymous (not verified) 75.89.77.218 Mind Body Soul 22, Inc. 101 South St. Delhi, IA 52223 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-31 Abby Paige DeGroot abby.whittenbaugh@gmail.com Delhi Deleware Iowa Kaes Christian DeGroot Michael David Whittenbaugh Signed (1) The corporation rejects the employers’ liability coverage. Abby Paige DeGroot abby@mbs22.com President Delhi Deleware Iowa Kaes Christian DeGroot Michael David Whittenbaugh Signed
394 2022-01-27 12:29 Anonymous (not verified) 72.255.65.83 Rodgers’ Building & Remodeling Inc 1003 NW 37th Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-28 Benjamin Rodgers btrdsm18@gmail.com Ankeny Polk Iowa Mary Rodgers Larry Joel Signed (1) The corporation rejects the employers’ liability coverage. Mary Rodgers steff.m2096@yahoo.com President Ankeny Polk Iowa Ben Rodgers Larry Joel Signed