843 |
2023-12-23 11:45 |
Anonymous (not verified) |
94.188.205.177 |
Janssen Handyman Service LLC |
503 Cherry Ave. Woodward, IA 50276 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-14 |
Cody A. Janssen |
janssenhandyman86@gmail.com |
Woodward |
Iowa |
Iowa |
Stephenie Janssen |
Glen Hall |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cody A. Janssen |
janssenhandyman86@gmail.com |
Owner |
Woodward |
Iowa |
Iowa |
Stephenie Janssen |
Glen Hall |
Signed |
842 |
2023-12-18 16:31 |
Anonymous (not verified) |
94.188.205.168 |
Brandon Clement |
3503 South Union St |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-18 |
Brandon Clement |
hawthornhill@paramark.us |
Des Moines |
Polk |
IA |
Brandi Haight |
Amanda Thompson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brandon Clement |
hawthornhill@paramark.us |
none |
Des Moines |
polk |
IA |
Brandi Haight |
Amanda Thompson |
Signed |
841 |
2023-12-18 16:28 |
Anonymous (not verified) |
94.188.205.168 |
Dennis Clement |
203 Astor St |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-18 |
Dennis Clement |
haight0929@gmail.com |
Des Moines |
Polk |
IA |
Amanda Thompson |
Brandi Haight |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dennis Clement |
haight0929@gmail.com |
none |
Des Moines |
polk |
IA |
Brandi Haight |
Amanda Thompson |
Signed |
840 |
2023-12-18 16:21 |
Anonymous (not verified) |
94.188.205.166 |
DC Painting Inc |
205 Astor St |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-18 |
Damion Clement |
amanda_thompson_marie@yahoo.com |
Des Moines |
polk |
IA |
Brandi Haight |
Amanda Thompson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Damion Clement |
amanda_thompson_marie@yahoo.com |
owner |
Des Moines |
Polk |
IA |
Brandi Haight |
Amanda Thompson |
Signed |
839 |
2023-12-18 16:12 |
Anonymous (not verified) |
94.188.207.227 |
515 Painting llc |
po box 157 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-18 |
Marvin S Parker JR |
stvpkr@gmail.com |
berwick |
polk |
iowa |
Christopher Eldridge |
Dillon Parker |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Marvin parker |
stvpkr@gmail.com |
owner |
berwick |
Polk |
Iowa |
Christopher Eldridge |
Dillon Parker |
Signed |
838 |
2023-12-14 08:57 |
Anonymous (not verified) |
94.188.207.223 |
Chuck Amling |
807 Main Street, Garber IA 52048 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-14 |
Chuck Amling |
mitzi@bruggemanlumber.com |
Garber |
IA |
United States |
Michelle Hoeger |
Roger Gibbs |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chuck Amling |
mitzi@bruggemanlumber.com |
Self |
Garber |
Clayton |
United States |
Michelle Hoeger |
Roger Gibbs |
Signed |
837 |
2023-12-13 08:51 |
Anonymous (not verified) |
94.188.207.228 |
J&M Tire and Repair LLC |
31006 Hedge Ave. |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-13 |
Jacob Mills Barkley |
jmtireandrepair@gmail.com |
Sioux city |
Plymouth |
Iowa |
Kevin Voth |
Evan Cook |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jacob Mills Barkley |
jmtireandrepair@gmail.com |
Owner |
Sioux City |
Plymouth |
Iowa |
Kevin Voth |
Evan Cook |
Signed |
836 |
2023-12-13 08:46 |
Anonymous (not verified) |
94.188.207.227 |
J&M Tire and Repair LLC |
31006 hedge ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-13 |
Macklin Paul Barkley |
barkley_mack@yahoo.com |
Merrill |
Plymouth |
Iowa |
Evan Cook |
Kevin Voth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Macklin Barkley |
jmtireandrepair@gmail.com |
Owner |
Merrill |
Plymouth |
Iowa |
Kevin Voth |
Evan Cook |
Signed |
835 |
2023-12-13 08:41 |
Anonymous (not verified) |
94.188.207.226 |
J&M Tire and Repair LLC |
31006 hedge ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-12-13 |
Jacob Mills Barkley |
jmtireandrepair@gmail.com |
sioux city |
Iowa |
United States |
Evan Cook |
Kevin Vothj |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jacob Mills Barkley |
jmtireandrepair@gmail.com |
Owner |
sioux city |
Iowa |
United States |
Evan Cook |
Kevin Voth |
Signed |
834 |
2023-12-13 08:35 |
Anonymous (not verified) |
94.188.207.228 |
PHOENIX CONSTRUCTION LLC |
2219 E 13TH ST DES MOINES, IA 50316 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-13 |
JUAN PABLO GUTIERREZ LEON |
jpgutierrez9000@yahoo.com |
DES MOINES |
IA |
IA |
DAISY VASQUEZ |
GRACIELA RODRIGUEZ |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
ARTURO SALGADO |
commercial@aksinsurance.com |
Insured |
Irving |
TX |
TX |
DAISY VASQUEZ |
GRACIELA RODRIGUEZ |
Signed |
833 |
2023-12-12 07:31 |
Anonymous (not verified) |
94.188.207.224 |
Axe-cade LLC |
136 E Main Street Anamosa, IA 52205 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-12 |
Teresa Coons |
axecadeonmain@gmail.com |
Anamosa |
Iowa |
United States |
Chad Coons |
Bret Funke |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chad Coons |
ccoons03@gmail.com |
Member |
Anamosa |
Iowa |
United States |
Teresa Coons |
Bret Funke |
Signed |
832 |
2023-12-07 09:57 |
Anonymous (not verified) |
94.188.207.226 |
Andrew Garberson |
400 SW 42nd Street, Des Moines, IA 50312 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-07 |
Andrew Garberson |
andrew.garberson@gmail.com |
Des Moines |
Polk |
IA |
Jeanette Harris |
Emily Feriz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andrew Garberson |
andrew.garberson@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Jeanette Harris |
Emily Feriz |
Signed |
831 |
2023-12-06 17:04 |
Anonymous (not verified) |
94.188.205.167 |
PHOENIX CONSTRUCTION LLC |
2219 E 13th St Des Moines, IA 50316 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-02 |
JUAN PABLO GUTIERREZ LEON |
jpgutierrez9000@yahoo.com |
Des Moines |
IA |
IA |
DAISY VASQUEZ |
Graciela Rodriguez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
arturo salgado |
fortworth@aksinsurance.com |
insured |
irving |
TX |
TX |
DAISY VASQUEZ |
DAISY VASQUEZ |
Signed |
830 |
2023-12-03 18:42 |
Anonymous (not verified) |
94.188.205.167 |
Custom Decks, LLC |
5719 Washington Ave, Des Moines, IA 50310-1072 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-03 |
Charles Dean Oakley IV |
oakleyoutdoorsolutions@gmail.com |
Carlisle |
Warren |
Iowa |
Sharon Marie Bracelin |
Casey John Eaton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Charles Dean Oakley IV |
Oakleyoutdoorsolutions@gmail.com |
Owner |
Carlisle |
Warren |
Iowa |
Casey John Eaton |
Sharon Marie Bracelin |
Signed |
829 |
2023-11-27 08:59 |
Anonymous (not verified) |
94.188.207.224 |
Adam Ruess Masonry |
206.w Elm st |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-27 |
Adam Ruess |
ruess33@gmail.com |
Lone Tree |
IA |
United States |
Adam Ruess |
Adam Ruess |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam Ruess |
ruess33@gmail.com |
Owner |
Lone Tree |
IA |
United States |
Adam Ruess |
Adam Ruess |
Signed |
828 |
2023-11-22 10:39 |
Anonymous (not verified) |
94.188.207.229 |
T&R Drywall LLC |
1450 NE 69th Pl Ste 56 Ankeny, IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-22 |
Julio Cazares Ornelas |
Special.t.d@hotmail.com |
Des Moines |
Polk |
Iowa |
Omar L Tippetts |
Omar L Tippetts Jr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
N/A |
special.t.d@hotmail.com |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
Signed |
827 |
2023-11-22 10:30 |
Anonymous (not verified) |
94.188.205.169 |
T&R Drywall LLC |
1450 NE 69th Pl Ste 56 Ankeny, IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-22 |
Roberto Javier Rodriguez Perez |
Special.t.d@hotmail.com |
Waukee |
Dallas |
IA |
Omar L Tippetts |
Omar L Tippetts Jr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
N/A |
special.t.d@hotmail.com |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
Signed |
826 |
2023-11-22 08:04 |
Anonymous (not verified) |
94.188.207.226 |
Sabuydee Corporation |
617 Davis Ave. / Corning, IA 50841 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-22 |
Adam Grundman |
adamgrundman@gmail.com |
Corning |
Adams |
Iowa |
Carol Penglase |
MIchael Grundman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam Grundman |
adamgrundman@gmail.com |
President |
Corning |
Iowa |
United States |
Carol Penglase |
Michael Grundman |
Signed |
825 |
2023-11-22 08:02 |
Anonymous (not verified) |
94.188.207.224 |
Sabuydee Corporation |
617 Davis Ave. / Corning, IA 50841 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-22 |
Nantawan Grundman |
lakejournal@gmail.com |
Corning |
Adams |
Iowa |
Carol Penglase |
Michael Grundman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam Grundman |
adamgrundman@gmail.com |
President |
Corning |
Iowa |
United States |
Carol Penglase |
Michael Grundman |
Signed |
824 |
2023-11-21 13:22 |
Anonymous (not verified) |
94.188.207.227 |
OhZone. LLC |
852 Washington Street Burlington, IA 52601 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-19 |
Jeffery W Ishmael |
jeffishmael@gmail.com |
Des Moines |
IA |
United States |
Juan DeLlanos |
Gregory Gunter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffery W Ishmael |
jeffishmael@gmail.com |
Co-Owner |
Des Moines |
IA |
United States |
Juan DeLlanos |
Gregory Gunter |
Signed |
823 |
2023-11-20 14:04 |
Anonymous (not verified) |
94.188.205.169 |
CDNE, Inc. |
311 E. Alta Vistta Ave. |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-20 |
Craig Allen Payne |
Craig.Payne@indianhills.edu |
Ottumwa |
Wapello |
Iowa |
Erin Elizabeth Payne |
Nathan Thomas Payne |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Desirae Lynn Payne |
desip845@gmail.com |
Spouse |
Ottumwa |
Wapello |
Iowa |
Erin Elizabeth Payne |
Nathan Thomas Payne |
Signed |
822 |
2023-11-20 09:43 |
Anonymous (not verified) |
94.188.207.223 |
Lifeson LLC |
303 6th Ave Coralville IA 52241 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-14 |
Scott Parshall |
scott@lifeson.com |
Coralville |
Johnson |
Iowa |
Samantha Mlavsky |
Pamela Mahon |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott Parshall |
scott@lifeson.com |
member |
Coralville |
Johnson |
Iowa |
Samantha Mlavsky |
Pamela Mahon |
Signed |
821 |
2023-11-17 13:30 |
Anonymous (not verified) |
94.188.207.230 |
ABC LOCK INC. |
2209 2nd Ave S. P.O. Box 433 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-17 |
Dennis Diekhuis |
keyman@cltel.net |
Clear Lake |
United States |
Iowa |
Dennis Diekhuis |
Dennis Diekhuis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dennis Diekhuis |
keyman@cltel.net |
Owner |
Clear lake |
United States |
Iowa |
Dennis Diekhuis |
Dennis Diekhuis |
Signed |
820 |
2023-11-16 14:32 |
Anonymous (not verified) |
94.188.205.175 |
T&R Drywall LLC |
1450 NE 69th Pl Ste 56 Ankeny, IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-01 |
Jonathan Manzano |
Special.t.d@hotmail.com |
Des Moines |
Polk |
IA |
Omar L Tippetts |
Omar L Tippetts Jr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
N/A |
special.t.d@hotmail.com |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
Signed |
819 |
2023-11-16 14:25 |
Anonymous (not verified) |
94.188.205.167 |
T&R Drywall LLC |
1450 NE 69th Pl Ste 56 Ankeny, IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-16 |
Jorge Marquez Soto |
Special.t.d@hotmail.com |
Des Moines |
Polk |
IA |
Omar L Tippetts |
Omar L Tippetts Jr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
N/A |
special.t.d@hotmail.com |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
Signed |
818 |
2023-11-16 13:34 |
Anonymous (not verified) |
94.188.207.230 |
T&R Drywall LLC |
1450 NE 69th Pl Ste 56 Ankeny, IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-16 |
N/A |
Special.t.d@hotmail.com |
N/A |
N/A |
N/A |
N/A |
N/A |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Manuel Velazquez |
special.t.d@hotmail.com |
owner |
Des Moines |
Polk |
IA |
Omar L Tippetts |
Omar L Tippetts Jr |
Signed |
817 |
2023-11-15 15:25 |
Anonymous (not verified) |
94.188.205.175 |
MO VALLEY TACO INC |
1971 LINCOLN HWY MISSOURI VALLEY IA 51555 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-01 |
REBECCA ALVAREZ |
abelardosmexicanfresh7@gmail.com |
MISSOURI VALLEY |
HARRISON |
IA |
GONZALO MUNOZ |
SILVIA CHAVEZ |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
REBECCA ALVAREZ |
abelardosmexicanfresh7@gmail.com |
OWNER |
MISSOURI VALLEY |
HARRISON |
IA |
GONZALO MUNOZ |
SILVIA CHAVEZ |
Signed |
816 |
2023-11-15 15:22 |
Anonymous (not verified) |
94.188.205.166 |
MO VALLEY TACO INC |
1971 LINCOLN HWY MISSOURI VALLEY IA 51555 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-01 |
MARTIN ALVAREZ |
abelardosmexicanfresh7@gmail.com |
MISSOURI VALLEY |
HARRISON |
IA |
GONZALO MUNOZ |
SILVIA CHAVEZ |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
MARTIN ALVAREZ |
abelardosmexicanfresh7@gmail.com |
OWNER |
MISSOURI VALLEY |
HARRISON |
IA |
GONZALO MUNOZ |
SILVIA CHAVEZ |
Signed |
815 |
2023-11-14 13:42 |
Anonymous (not verified) |
94.188.207.224 |
SunsetSue, LLC |
240 Solomia Court, Peosta, IA 52068 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-14 |
Lori Sue Stewart |
lori@hrbcplus.com |
Peosta |
IA |
United States |
Mark R Stewart |
Danielle M Leibfried |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lori S Stewart |
lori@hrbcplus.com |
Self |
Peosta |
IA |
United States |
Mark R Stewart |
Danielle M. Leibfried |
Signed |
814 |
2023-11-14 13:11 |
Anonymous (not verified) |
94.188.207.225 |
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. |
2023-11-14 |
Garrett Allen Reno |
garrettreno2001@gmail.com |
Tipton |
Cedar |
Iowa |
Bridget Camp |
Tarin Erenberger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Garrett Reno |
garrettreno2001@gmail.com |
Self |
Tipton |
Cedar |
Iowa |
Bridget Camp |
Tarin Erenberger |
Signed |
813 |
2023-11-14 13:00 |
Anonymous (not verified) |
94.188.207.226 |
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. |
2023-11-14 |
Garrett Allen Reno |
garrettreno2001@gmail.com |
Tipton |
Cedar |
Iowa |
Bridget Camp |
Tarin Erenberger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tarin Erenberger |
tarin.nexlevelusa@gmail.com |
Operations Director |
Cedar Rapids |
Linn |
Iowa |
Bridget Camp |
Garrett Reno |
Signed |
812 |
2023-11-11 19:26 |
Anonymous (not verified) |
94.188.207.230 |
Bikes To You Inc |
921 Broad St. |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-11 |
Craig Cooper |
craig@bikestoyou.com |
Grinnell |
Poweshiek |
Iowa |
Dave Huff |
Marge Huff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Craig Cooper |
craig@bikestoyou.com |
President |
Grinnell |
Poweshiek |
Iowa |
Dave Hiff |
Marge Huff |
Signed |
811 |
2023-11-11 11:04 |
Anonymous (not verified) |
94.188.205.175 |
PJ Trucking Unlimited LLC |
2617 380th Ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-11 |
Peggy Jensen |
pegandhalj@gmail.com |
Farragut |
Fremont |
IA |
Darlene Carpenter |
Julie Marshall |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Peggy Jensen |
pegandhalj@gmail.com |
Member |
Farragut |
Fremont |
IA |
Darlene Carpenter |
Julie Marshall |
Signed |
810 |
2023-11-09 17:41 |
Anonymous (not verified) |
94.188.205.167 |
Chad Ripple's Painting LLC |
899 NW 45th Ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-09 |
Chad Ripple |
ia515@hotmail.com |
Des Moines |
Polk |
Iowa |
Ron Spurgeon |
Brandon Haus |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chad Ripple |
ia515@hotmail.com |
President |
Des Moines |
Polk |
Iowa |
Ron Spurgeon |
Brandon Haus |
Signed |
809 |
2023-11-08 09:47 |
Anonymous (not verified) |
94.188.207.229 |
GruntWorkz Wedling and Fab, Inc. |
15519 80th Ave Blue Grass, IA 52726 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-08 |
Brandon Joseph Fox |
GruntWorkzwelding@gmail.com |
Blue Grass |
Scott |
Iowa |
Amanda Dawn Fox |
Brandon Joseph Fox |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brandon Joseph Fox |
GruntWorkzwelding@gmail.com |
Same Person |
Blue Grass |
Scott |
Iowa |
Amanda Dawn Fox |
Brandon Joseph Fox |
Signed |
808 |
2023-11-08 07:37 |
Anonymous (not verified) |
94.188.207.229 |
Cush Comfort |
1225 e. River Dr STE 206 Davenport IA 52803 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-30 |
Chris Cushman |
ccushman82@gmail.com |
Milan |
IL |
United States |
Deena Maurus |
Jenna Ortberg |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christopher Cushman |
ccushman82@gmail.com |
Owner |
Milan |
IL |
United States |
Deena Maurus |
Jenna Ortberg |
Signed |
807 |
2023-11-07 11:25 |
Anonymous (not verified) |
94.188.205.167 |
Keokuk Termite & Pest Control, INC. |
P.O.Box 422 Keokuk, IA 52632 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-07 |
Marc Lee Floyd |
keokuktermite@gmail.com |
Keokuk |
Lee |
Iowa |
Kayla Joanne Tonkin |
Esther Mae Floyd |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Marc Lee Floyd |
keokuktermite@gmail.com |
Owner |
Keokuk |
Lee |
Iowa |
Kayla Joanne Tonkin |
Esther Mae Floyd |
Signed |
806 |
2023-11-06 13:52 |
Anonymous (not verified) |
94.188.205.168 |
Southeast Iowa behavioral Healthcare center |
101 north 12th keokuk ia |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-06 |
Kendall elder |
klelder48@gmail.com |
Keokuk |
Lee |
Iowa |
Kendall elder |
Darian Miller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tami elder |
telder@leximgtoncg.com |
Payroll |
Keokuk |
Lee |
Iowa |
Kendall elder |
Darian miller |
Signed |
805 |
2023-10-31 14:53 |
Anonymous (not verified) |
94.188.207.225 |
PJ Trucking Unlimited LLC |
2617 380th Ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-31 |
Peggy Jensen |
pegandhalj@gmail.com |
Farragut |
Fremont |
Iowa |
Julie Marshall |
Darlene Carpenter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Peggy Jensen |
pegandhalj@gmail.com |
Member |
Farragut |
US |
US |
Julie Marshall |
Darlene Carpenter |
Signed |
804 |
2023-10-31 13:04 |
Anonymous (not verified) |
94.188.207.226 |
NeX Level Restoration LLC |
314 8th ST NW, Cedar Rapids, IA 52405 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-31 |
Bobby Caldwell SR |
blc5000@msn.com |
Cedar Rapids |
Linn |
IA |
Adam Feldmann |
Tarin Tanner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bobby Caldwell |
blc5000@msn.com |
Self |
Cedar Rapids |
Linn |
IA |
Adam Feldmann |
Tarin Tanner |
Signed |
803 |
2023-10-25 08:37 |
Anonymous (not verified) |
94.188.205.166 |
CEM Businesses LLC |
608 Evergreen Cir NW Bondurant, IA 50035 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-25 |
Ryan Canales |
ryancanales44@gmail.com |
West Des Moines |
Polk |
Iowa |
Raelynn Aicher |
Cameron VanBuren |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Dane McDonald |
dane.mcdonald@stellar-solar.net |
Self |
Bondurant |
Polk |
Iowa |
Raelynn Aicher |
Cameron VanBuren |
Signed |
802 |
2023-10-25 08:34 |
Anonymous (not verified) |
94.188.205.174 |
CEM Businesses LLC |
607 evergreen cir nw Bondurant, IA 50035 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-10-25 |
Dustin Rudolph |
dmrudo@gmail.com |
Des Moines |
Polk |
Iowa |
Cameron VanBuren |
Raelynn Aicher |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dane McDonald |
dane.mcdonald@stellar-solar.net |
Self |
Bondurant |
Polk |
Iowa |
Cameron VanBuren |
Raelynn Aicher |
Signed |
801 |
2023-10-25 08:32 |
Anonymous (not verified) |
94.188.205.177 |
CEM Businesses LLC |
608 Evergreen Cir NW Bondurant, IA 50035 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-10-25 |
Dane McDonald |
danemcdonald2@gmail.com |
Bondurant |
Polk |
Iowa |
Raelynn Aicher |
Cameron VanBuren |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dane McDonald |
dane.mcdonald@stellar-solar.net |
Self |
Bondurant |
Polk |
Iowa |
Raelynn Aicher |
Cameron VanBuren |
Signed |
800 |
2023-10-23 07:40 |
Anonymous (not verified) |
94.188.207.228 |
Lucas construction inc |
1707 mondamin ave des moines , Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-23 |
Luis Arturo Martinez Lucas |
luiss_95@icloud.com |
Des Moines |
USA |
Iowa |
Cristian António Martínez Lucas |
Manuel canizales |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Luis Arturo Martinez Lucas |
luiss_95@icloud.com |
President |
Des Moines |
Usa |
Iowa |
Cristian António Martínez Lucas |
Manuel canizales |
Signed |
799 |
2023-10-20 11:28 |
Anonymous (not verified) |
94.188.205.169 |
JC Roofing |
2320 SE 17th Street 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. |
2023-10-20 |
Jose Antonio Ayala Contreras |
josecontrerasroofing91@gmail.com |
Des Moines |
Polk |
Iowa |
Jessica Newton |
Tom Newton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jose Antonio Ayala Contreras |
josecontrerasroofing91@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Jessica Newon |
Tom Newton |
Signed |
798 |
2023-10-20 10:54 |
Anonymous (not verified) |
94.188.205.177 |
Connerley Construction Inc |
5915 4Th St. SW Cedar Rapids, Iowa 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-20 |
Allen Connerley |
betterrentalsbyconnerley@aol.com |
CEDAR RAPIDS |
Linn |
Iowa |
Nika Mefford |
Duane Anderson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Connerley Construction Inc |
Connerleyconstruction@gmail.com |
Owner |
Cedar Rapids |
Linn |
IA |
Nika Mefford |
Duane Anderson |
Signed |
797 |
2023-10-20 07:04 |
Anonymous (not verified) |
94.188.205.175 |
T&R Drywall LLC |
1450 NE 69th Pl Ste 56 Ankeny IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-20 |
Jose Castro |
special.t.d@hotmail.com |
Des Moines |
Polk County |
Iowa |
Omar Tippetts |
Omar Tippetts Jr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
N/A |
special.t.d@hotmail.com |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
Signed |
796 |
2023-10-18 14:34 |
Anonymous (not verified) |
94.188.205.177 |
Yarn Tree Designs Inc |
117 Alexander Ave, Ames, IA 50010 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-18 |
Larry R Johnson |
larry@yarntree.com |
Ames |
Story |
Iowa |
Megan Chriswisser |
Erica Lenig |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Larry R Johnson |
larry@yarntree.com |
VP |
Ames |
Story |
Iowa |
Megan Chriswisser |
Erica Lenig |
Signed |
795 |
2023-10-18 14:29 |
Anonymous (not verified) |
94.188.205.169 |
Yarn Tree Designs Inc |
117 Alexander Ave, Ames, IA 50010 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-18 |
Sarah Beth Johnson |
Beth@yarntree.com |
Ames |
Story |
Iowa |
Megan Chriswisser |
Erica Lenig |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Larry R Johnson |
larry@yarntree.com |
VP |
Ames |
Story |
Iowa |
Megan Chriswisser |
Erica Lenig |
Signed |
794 |
2023-10-18 08:21 |
Anonymous (not verified) |
94.188.205.177 |
J&M Tire and Repair |
31006 hedge ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-18 |
Macklin Paul Barkley |
flyingtank92@yahoo.com |
merrill |
Iowa |
United States |
Brandon Norris |
Alex Barkley |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Macklin Paul Barkley |
jmtireandrepair@gmail.com |
Owner |
sioux city |
Iowa |
United States |
Brandon Norris |
Alex Barkley |
Signed |