893 |
2024-02-22 10:29 |
Anonymous (not verified) |
94.188.207.226 |
Sierra Roofing |
401 W 15th Street West Liberty, IA 52776 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-22 |
Abraham Granjeno Sierra |
absierra89@gmail.com |
West Liberty |
Muscatine |
Iowa |
Claudia Venable |
Dan Saunders |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Abraham Granjeno Sierra |
absierra89@gmail.com |
Owner/Self |
West Liberty |
Muscatine |
Iowa |
Claudia Venable |
Dan Saunders |
Signed |
892 |
2024-02-21 16:55 |
Anonymous (not verified) |
94.188.205.167 |
NeX Level Restoration |
314 8th ST NW Cedar Rapids, IA 52405 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-21 |
Kenneth Williams |
kncwilliams@msn.com |
Cedar Rapids |
Linn |
Iowa |
Sabrina Lovell |
Tiffany Williams |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kenneth Williams |
kncwilliams@msn.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Sabrina Lovell |
Tiffany Williams |
Signed |
891 |
2024-02-19 12:09 |
Anonymous (not verified) |
94.188.205.169 |
FJ Orisa Construction Inc |
114 Austin Street SW |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-19 |
Felipe Aldana |
FJOrisaconstruction@yahoo.com |
Cedar Rapids |
Linn |
IA |
Karen Sedlacek |
Billie Jo Moore |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Felipe Aldana |
FJOrisaconstruction@yahoo.com |
officer |
Cedar Rapids |
Iowa |
Iowa |
Karen Sedlacek |
Billie Jo Moore |
Signed |
890 |
2024-02-19 12:07 |
Anonymous (not verified) |
94.188.205.174 |
FJ Orisa Construction Inc |
114 Austin Street SW |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-19 |
Jennifer LynnWeirup |
FJOrisaconstruction@yahoo.com |
Cedar Rapids |
Linn |
IA |
Karen Sedlacek |
Billie Jo Moore |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
jennifer lynn weirup |
FJOrisaconstruction@yahoo.com |
self |
Cedar Rapids |
Iowa |
Iowa |
Karen Sedlacek |
Billie Jo Moore |
Signed |
889 |
2024-02-15 13:16 |
Anonymous (not verified) |
94.188.207.228 |
Five Star Hardwood LLC |
3510 King Dr SW |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-15 |
Kenneth Williams |
kncwilliams@msn.com |
Cedar Rapids |
Linn |
IA |
Sabrina Lovell |
Tiffany Williams |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kenneth Williams |
kncwilliams@msn.com |
Owner |
Cedar Rapids |
Linn |
IA |
Sabrina Lovell |
Tiffany Williams |
Signed |
888 |
2024-02-12 12:35 |
Anonymous (not verified) |
94.188.205.167 |
Standard Builders DBA Midwest Seamless |
1930 e army post rd., Des Moines IA |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-12 |
Andy and Axell Construction LLC |
bradymaher9@gmail.com |
Des Moines |
Polk |
IA |
Michael Maher |
Brady Maher |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
michael maher |
mikemaher@midwestseamless.com |
Owner/President |
PRAIRIE CITY |
Jasper |
IA |
Brady Maher |
fernando perez |
Signed |
887 |
2024-02-08 13:40 |
Anonymous (not verified) |
94.188.207.228 |
Paradigm Construction |
3263 Cumming Rd. Cumming, IA 50061 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-08 |
Justin Huss |
jmanhuss@gmail.com |
Grimes |
Polk |
Iowa |
Katie Hennessey |
Ryan Shabino |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ryan Shabino |
office@prdgmgroup.com |
Owner |
Cumming |
Warren |
Iowa |
Katie Hennessey |
Nicole Shabino |
Signed |
886 |
2024-02-06 19:20 |
Anonymous (not verified) |
94.188.207.227 |
juan carlos ruiz perez |
2010 seventh st desmoines, ia 50314 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-06 |
juan carlos ruiz perez |
jruizperez898@gmail.com |
desmoines |
polk |
iowa |
guadalupe Gonzalez rojo |
Javier Villeda Hernandez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
juan c ruiz perez |
jruizperez898@gmail.com |
owner |
desmoines |
polk |
in |
guadalupe gonzalez rojo |
Javier Villeda Hernandez |
Signed |
885 |
2024-02-06 15:20 |
Anonymous (not verified) |
94.188.205.177 |
JUAN GOMEZ LOPEZ |
833 E UNIVERSITY AVE, DESMOINES,IA APT 1 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-06 |
JUAN GOMEZ LOPEZ |
juangomezlopez057@gmail.com |
desmoines |
polk |
IOWA |
PRICILA RUBI MONDRAGON |
pedro gomez lopez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
juan gomez lopez |
juangomezlopez057@gmail.com |
owner |
desmoines |
polk |
iowa |
pricila rubi mondragon |
pedro gomez lopez |
Signed |
884 |
2024-02-05 11:31 |
Anonymous (not verified) |
94.188.205.175 |
NeX Level Moving LLC |
5634 Deerwood ST SW cedar rapids iowa 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-05 |
Robert Sanders |
Sandersrob101300@gmail.com |
Cedar Rapids |
Linn |
Iowa |
dallas haul |
johntay buck |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Sanders |
Sandersrob101300@gmail.com |
self |
cedar rapids |
linn |
iowa |
dallas haul |
Johntay buck |
Signed |
883 |
2024-02-05 11:29 |
Anonymous (not verified) |
94.188.205.175 |
Nex Level Moving LLC |
5634 Deerwood ST SW cedar rapids iowa 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-05 |
Robert Sanders |
Sandersrob101300@gmail.com |
Cedar Rapids |
Linn |
Iowa |
n/a |
n/a |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Sanders |
Sandersrob101300@gmail.com |
self |
cedar rapids |
linn |
iowa |
n/a |
n/a |
Signed |
882 |
2024-02-05 11:18 |
Anonymous (not verified) |
94.188.205.175 |
next level moving |
1186 Capital Dr Sw cedar rapids iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2024-02-05 |
Robert Sanders |
sandersrob101300@gmail.con |
cedar rapids |
linn |
iowa |
phoenix sims |
n/a |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
next level moving |
tarin.nexlevelmoving@gmail.com |
labor |
cedar rapids |
linn |
iowa |
n/a |
n/a |
Signed |
881 |
2024-02-05 11:08 |
Anonymous (not verified) |
94.188.205.168 |
Nxt Level |
1186 Capital Dr sw |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2024-02-05 |
Robert Sanders |
Sandersrob101300@gnail.com |
cedar rapids |
Linn |
iowa |
n/a |
n/a |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
next level |
nextlevelmoving@gmail.com |
labor |
cedar rapids |
linn |
iowa |
n/a |
n/a |
Signed |
880 |
2024-02-04 18:45 |
Anonymous (not verified) |
94.188.205.176 |
One Call Exteriors |
1928 9th St Des Moines IA 50314 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-04 |
Nancy López |
onecallexteriors@gmail.com |
Des Moines |
Polk |
IA |
Noé Ordaz |
Angie Florian |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nancy López |
onecallexteriors@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Noé Ordaz |
Angie Florian |
Signed |
879 |
2024-02-02 15:24 |
Anonymous (not verified) |
94.188.205.169 |
Open Road Driving School.com INC |
2418 Paradise Ct Kalona, Iowa 52247 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-02 |
Jennifer Turner |
jenny@openroaddrivingschool.com |
Kalona |
Washington |
Iowa |
Lonnie Slabaugh |
Joshua Turner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jennifer Turner |
jenny@openroaddrivingschool.com |
president |
Kalona |
Washington |
Iowa |
Lonnie Slabaugh |
Joshua Turner |
Signed |
878 |
2024-02-02 15:22 |
Anonymous (not verified) |
94.188.207.223 |
Open Road Driving School.com INC |
2418 Paradise Ct Kalona, Iowa 52247 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-02 |
Ryan Turner |
ryanturner@citypoint.cc |
Kalona |
Washington |
IOwa |
Lonnie Slaubaugh |
Joshua Turner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ryan Turner |
ryanturner@citypoint.cc |
Secretary |
Kalona |
Washington |
Iowa |
Lonnie Slabaugh |
Joshua Turner |
Signed |
877 |
2024-01-30 17:58 |
Anonymous (not verified) |
94.188.207.230 |
Erik Mortens |
9823 nw 46th ct polk city iowa 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-30 |
Steffanie Mortens |
steffanie.mortens@gmail.com |
Polk city |
Polk |
Iowa |
Andrea Davis |
Kali Davis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik mortens |
Erik.mortens@gmail.com |
Self |
Polk city |
Polk |
Iowa |
Kali Davis |
Andrea Davis |
Signed |
876 |
2024-01-30 17:55 |
Anonymous (not verified) |
94.188.207.230 |
Erik Mortens |
9823 nw 46th ct polk city iowa 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-30 |
Erik mortens |
Erik.mortens@gmail.com |
Polk city |
Polk |
Iowa |
Andrea Davis |
Kali Davis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik mortens |
Erik.mortens@gmail.com |
Self |
Polk city |
Polk |
Iowa |
Kali Davis |
Andrea Davis |
Signed |
875 |
2024-01-30 14:18 |
Anonymous (not verified) |
94.188.207.226 |
Central Athletics LLC |
7 S 4th Street Council Bluffs Iowa 51503 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-30 |
Cait Boyer |
centralathleticsia@gmail.com |
Council Bluffs |
Pottawattamie |
Iowa |
Justice Woolard |
Erin Eby |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cait Boyer |
centralathleticsia@gmail.com |
President |
Council Bluffs |
Pottawattamie |
Iowa |
Justice Woolard |
Erin Eby |
Signed |
874 |
2024-01-29 14:30 |
Anonymous (not verified) |
94.188.205.174 |
Proefco LLC |
502 s Cadwell AVE |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-30 |
Kendy Melendrez |
kendydej@gmail.com |
Eagle Grove |
IA |
IA |
Kendy Melendrez |
Jaime Hernandez |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Kendy Melendrez |
kendydej@gmail.com |
owner |
Eagle Grove |
IA |
IA |
Kendy Melendrez |
Jaime Hernandez |
Signed |
873 |
2024-01-26 12:02 |
Anonymous (not verified) |
94.188.207.224 |
Bowlerama, Inc. |
1313 East Diehl St. Des Moines, IA 50315 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-26 |
Michael Klimpel |
Klimpel@aol.com |
Rosemount |
MN |
United States |
Eric Stahl |
Connie Hill |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Michael Klimpel |
Klimpel@aol.com |
President |
Rosemount |
MN |
United States |
Eric Stahl |
Connie Hill |
Signed |
872 |
2024-01-26 10:28 |
Anonymous (not verified) |
94.188.205.177 |
Sole proprietor- Dennis R. Oliver dba Olivers Oasis Communications |
150 Spring Valley Ct. Springtown, TX 76082 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-26 |
Dennis Reeves Oliver |
doliversoasis@aol.com |
Springtown |
Parker |
Texas |
Helen Frances Steil |
John Kevin Steil |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dennis Reeves Oliver |
doliversoasis@aol.com |
Self |
Springtown |
Parker |
TX |
Helen Frances Steil |
John Kevin Steil |
Signed |
871 |
2024-01-26 09:16 |
Anonymous (not verified) |
94.188.205.168 |
NeX Level Restoration |
314 8th St NW, Cedar Rapids, IA, 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-26 |
Trevor McCauley |
jhawktm@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Bridget Camp |
Bridget Camp |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Trevor McCauley |
jhawktm@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Bridget Camp |
Bridget Camp |
Signed |
870 |
2024-01-26 07:57 |
Anonymous (not verified) |
94.188.207.228 |
Kodiak Group Security LLC |
1978 NW 92nd CT STE 2 Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-23 |
Howard Alton Johnston Jr |
howard@kodiakgroup.org |
Stuart |
Adair |
IA |
Joseph Crawford |
Howard Williams |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Howard Alton Johnston Jr |
howard@kodiakgroup.org |
Owner |
Stuart |
Adair |
Iowa |
Jospeh Crawford |
Howard Williams |
Signed |
869 |
2024-01-25 14:19 |
Anonymous (not verified) |
94.188.207.227 |
Christensen Leasing LLC |
1008 Brooks North Lane |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-25 |
Michael Christensen |
cconmichael@gmail.com |
Okoboji |
Dickinson |
Iowa |
Roger Christensen |
Dan Christensen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Christensen |
cconmichael@gmail.com |
Owner |
Okoboji |
Dickinson |
Iowa |
Roger Christensen |
Dan Christensen |
Signed |
868 |
2024-01-25 14:08 |
Anonymous (not verified) |
94.188.207.229 |
NeX Level Moving, LLC |
5634 Deerwood St. SW, Cedar Rapids, IA, 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-25 |
Trevor McCauley |
jhawktm@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Bridget |
Camp |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Trevor McCauley |
jhawktm@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Bridget Camp |
Trevor McCauley |
Signed |
867 |
2024-01-24 15:04 |
Anonymous (not verified) |
94.188.207.227 |
Shook Handyman |
2415 Plum Creek Rd |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-24 |
Nolan Shook |
office@shookhandyman.com |
Sioux City |
Woodbury |
IA |
McKenna Warner |
Jessica Shook |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Susan Geist |
sgeist@paychex.com |
Paychex Insurance Agency Inc |
Rochester |
Monroe |
NY |
Nolan Shook |
McKenna Warner |
Signed |
866 |
2024-01-23 14:40 |
Anonymous (not verified) |
94.188.207.225 |
Firm Foundation Concrete |
PO Box 164 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-23 |
Lyle Schut |
firmfoundationbros@gmail.com |
Sioux Center |
Sioux |
Iowa |
Erica Schut |
Miguel Perez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lyle Schut |
firmfoundationbros@gmail.com |
Owner |
Sioux Center |
Sioux |
IA |
Erica Schut |
Miguel Perez |
Signed |
865 |
2024-01-23 14:32 |
Anonymous (not verified) |
94.188.205.177 |
Josh Oswald |
505 Eisenhower Rd., Osceola, IA 50213 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-23 |
Joshua Oswald |
jjoswald47@gmail.com |
Osceola |
Clarke |
Iowa |
Douglas Eugene Miller |
Elaine Lee |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joshua Oswald |
jjoswald47@gmail.com |
Owner/Sole Proprietor |
Osceola |
Clarke |
Iowa |
Douglas Eugene Miller |
Elaine Lee |
Signed |
864 |
2024-01-23 14:31 |
Anonymous (not verified) |
94.188.207.230 |
Firm Foundation Concrete |
PO Box 164 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-23 |
Greg Schut |
firmfoundationbros@gmail.com |
Sioux Center |
Sioux |
Iowa |
Erica Schut |
Miguel Perez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Greg Schut |
firmfoundationbros@gmail.com |
Owner |
Sioux Center |
Sioux |
IA |
Erica Schut |
Miguel Perez |
Signed |
863 |
2024-01-23 13:59 |
Anonymous (not verified) |
94.188.205.176 |
United Marble & Tile, Inc. |
915 8th Street, #201, Boone, IA. 50036 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-24 |
Albert James Gotta |
jim@umtile.com |
Slater |
Boone |
IA |
Antonina M Gotta |
MARY KATE RUSSELL |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Albert James Gotta |
jim@umtile.com |
President Sole Share Holder |
Boone |
IA |
IA |
Antonina M Gotta |
Antonina M Gotta |
Signed |
862 |
2024-01-22 13:55 |
Anonymous (not verified) |
94.188.207.228 |
Emcubed Enterprises, Inc |
979 40th Ave, Bettendorf, IA 52722 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-22 |
Bradley D Morrison |
brad@riverbendsignworks.com |
Moline |
Rock Island |
IL |
Richard Henning |
Kyle Sebben |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Morrison |
brad@riverbendsignworks.com |
Owner |
Moline |
Rock Island |
IL |
Richard Henning |
Kyle Sebben |
Signed |
861 |
2024-01-19 11:52 |
Anonymous (not verified) |
94.188.207.228 |
Nex level moving llc |
5634 Deerwood ST SW, Cedar Rapids, IA 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-19 |
Martavian |
mborseth0110@gmail.com |
Cedar rapids |
Linn |
Iowa |
Christine B. |
Jenny B. |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Martavian Borseth |
mborseth0110@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Christine B. |
Jenny B. |
Signed |
860 |
2024-01-19 08:59 |
Anonymous (not verified) |
94.188.205.168 |
T&R Drywall LLC |
1450 NE 69th Pl Ste 56 Ankeny, IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-19 |
Carmelo Chavez |
Special.t.d@hotmail.com |
Des Moines |
Polk |
Iowa |
Omar L Tippetts |
Omar L Tippetts Jr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
N/A |
special.t.d@hotmail.com |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
Signed |
859 |
2024-01-19 06:38 |
Anonymous (not verified) |
94.188.205.166 |
D & G Communications |
405 1st Street N. Farley, Iowa 52046 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-19 |
David William Hirsch |
dngcomm@hotmail.com |
Farley |
Dubuque |
Iowa |
Gina Hirsch |
Micki Jones |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dave Hirsch |
dngcomm@hotmail.com |
Owner |
Farley |
Dubuque |
Iowa |
Gina Hirsch |
Micki Jones |
Signed |
858 |
2024-01-18 08:24 |
Anonymous (not verified) |
94.188.207.226 |
Custom Flooring LLC |
7085 Bloomfield Road Lot 249 Des Moines, Iowa 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-18 |
Jesus Vera |
jesusvera199027@icloud.com |
Des Moines |
Polk |
Iowa |
Natalia Vera |
Adriana de Anda |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jesus Vera |
jesusvera199027@icloud.com |
Owner |
Des Moines |
Polk |
Iowa |
Natalia Vera |
Adriana de Anda |
Signed |
857 |
2024-01-17 16:04 |
Anonymous (not verified) |
94.188.205.167 |
GA Drywall LLC |
1906 West State Street Marshalltown Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-17 |
Oscar Vazquez LOPEZ |
gadrywall7@icloud.com |
Marshalltown |
Marshall |
Iowa |
Ana Ibarra |
Ana Lopez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Oscar Vazquez Lopez |
oscarlopez177@icloud.com |
Owner |
Marshalltown |
Marshall |
Iowa |
Ana Ibarra |
Ana Lopez |
Signed |
856 |
2024-01-17 15:09 |
Anonymous (not verified) |
94.188.205.167 |
Nex Level Moving, LLC |
5634 Deerwood Dr SW |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-17 |
LaPriest Green |
lapriestg@gmail.com |
Cedar Rapids |
Linn County |
Iowa |
Adam Feldmann |
LaPriest Green |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LaPriest Green |
lapriestg@gmail.com |
Employee |
Cedar Rapids |
Linn County |
Iowa |
Adam Feldmann |
LaPriest Green |
Signed |
855 |
2024-01-17 14:55 |
Anonymous (not verified) |
94.188.205.177 |
NexLevel Moving |
5634 Deerwood Dr Sw |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-17 |
LaPriest Green |
lapriestg@gmail.com |
Cedar Rapids |
Linn County |
Iowa |
Adam Feldmann |
LaPriest Green |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LaPriest Green |
lapriestg@gmail.com |
Employee |
Cedar Rapids |
Linn County |
Iowa |
Adam Feldmann |
LaPriest Green |
Signed |
854 |
2024-01-16 14:59 |
Anonymous (not verified) |
94.188.207.226 |
AJS Sanitation LLC |
504 Locust, St, PO Box 144, Minburn, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-16 |
Jason Mash |
jmash79@yahoo.com |
Minburn |
Dallas |
Iowa |
Don Richardson |
Abbey Luellen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jason Mash |
jmash79@yahoo.com |
President |
Minburn |
Dallas |
Iowa |
Don Richardson |
Abbey Luellen |
Signed |
853 |
2024-01-16 13:21 |
Anonymous (not verified) |
94.188.207.230 |
NeX Level Moving |
5634 Deerwood St SW Cedar Rapids, IA 52404 United States |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-16 |
Hayden Schaefer Wagner |
24haywag24@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Stephanie Allegra Wagner |
Hayden Schaefer Wagner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Hayden Schaefer Wagner |
24haywag24@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Hayden Schaefer Wagner |
Stephanie Allegra Wagner |
Signed |
852 |
2024-01-14 15:48 |
Anonymous (not verified) |
94.188.205.166 |
B St. Construction + Design, Inc. |
16 Southwest 42nd Street |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-14 |
Travis D Crouch |
trvscrouch@gmail.com |
Des Moines |
Iowa |
United States |
Jodi Essex |
Linda K Renze |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Travis D Crouch |
trvscrouch@gmail.com |
President |
Des Moines |
IA |
United States |
Jodi Essex |
Linda K Renze |
Signed |
851 |
2024-01-14 15:40 |
Anonymous (not verified) |
94.188.205.169 |
B St. Construction + Design, Inc. |
16 Southwest 42nd Street |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-13 |
Emily Renze-Crouch |
emily@bstdesigner.com |
Des Moines |
Iowa |
United States |
Jodi Essex |
Linda K Renze |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Emily Renze-Crouch |
emily@bstdesigner.com |
Vice President / CFO |
Des Moines |
IA |
United States |
Jodi Essex |
Linda K Renze |
Signed |
850 |
2024-01-11 15:22 |
Anonymous (not verified) |
94.188.205.167 |
CUB CONSTRUCTION LLC |
4243 GRANDVIEW AVE, DES MOINES, IOWA 50317 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-11 |
SUSANA MELENDEZ |
melendezsusana342@gmail.com |
Des Moines |
Polk |
Iowa |
Elsa Villanueva |
Jaime Leiva |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Susana Melendez |
melendezsusana342@gmail.com |
Owner |
Des Moines |
Pok |
Iowa |
Elsa Villanueva |
Jaime Leiva |
Signed |
849 |
2024-01-10 10:47 |
Anonymous (not verified) |
94.188.205.166 |
RedZone Football Academy LLC |
2000 James St. Suite 205, Coralville, IA 52241 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-10 |
Tyler James Blum |
blum.tyler@gmail.com |
Oxford |
Johnson |
Iowa |
Cole Davis |
Trevor Bollers |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tyler Blum |
redzonefbacademy@gmail.com |
same person, single member LLC/corp |
Oxford |
Johnson |
Iowa |
Cole Davis |
Trevor Bollers |
Signed |
848 |
2024-01-05 13:05 |
Anonymous (not verified) |
94.188.205.177 |
NeX Level Moving, LLC |
5634 Deerwood St. SW, Cedar Rapids, IA, 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-05 |
William J Feldmann |
feldmannwng@msn.com |
Anamosa |
Jones |
Iowa |
Bridget |
Camp |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William J Feldmann |
feldmannwng@msn.com |
Self |
Anamosa |
Jones |
Iowa |
Bridget |
Camp |
Signed |
847 |
2024-01-04 21:10 |
Anonymous (not verified) |
94.188.207.227 |
C & L Construction |
721 NE 60th St, Pleasant Hill, IA 50327 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-04 |
Jose M Sanchez Melendez |
landerosmary@gmail.com |
Pleasant Hill |
Polk |
Iowa |
Marianna Landeros |
Cheryl Martinez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jose M Sanchez Melendez |
landerosmary@gmail.com |
Self |
Pleasant Hill |
Polk |
Iowa |
Marianna Landeros |
Cheryl Martinez |
Signed |
846 |
2024-01-03 14:13 |
Anonymous (not verified) |
94.188.205.168 |
Madison County Renovations Inc |
PO Box 521, Winterset, IA 50273 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-03 |
Jonathan Hays |
17jhays@gmail.com |
Waukee |
Dallas |
IA |
Rachel Anderson |
Roger Queck |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mark Hays |
mark.hays88@yahoo.com |
President |
Winterset |
Madison |
Iowa |
Rachel Anderson |
Roger Qyeck |
Signed |
845 |
2024-01-02 09:03 |
Anonymous (not verified) |
94.188.205.169 |
American Tree Service LLC |
416 S Kiel Street, Holstein, IA 51025 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-02 |
Austin Thevenot |
americantreeservice03@gmail.com |
Holstein |
Ida |
Iowa |
Jared Brashears |
Katie Gunkelman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Austin Thevenot |
americantreeservice03@gmail.com |
Owner |
Holstein |
Ida |
Iowa |
Jared Brashears |
Katie Gunkelman |
Signed |
844 |
2023-12-29 08:28 |
Anonymous (not verified) |
94.188.207.226 |
Emcubed Enterprises, Inc |
979 40th Ave, Bettendorf, IA 52722 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-29 |
Bradley David Morrison |
brad@riverbendsignworks.com |
Moline |
Rock Island |
IL |
David Rodriguez |
Lisbet Lule |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradley David Morrison |
brad@riverbendsignworks.com |
Owner |
Moline |
Rock Island |
IL |
David Rodriguez |
Lisbet Lule |
Signed |