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Rejection of Workers' Compensation or Employers' Liability Coverage

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# Submitted User IP address Name of Corporation: Address of Corporation Home Office: Statement 1 Agreement: Statement 2 Agreement: Statement 3 Agreement: Statement Agreement: Check Either Alternative (1) or (2): Date: Full Name of Individual: Email: City of Residence: County of Residence: State of Residence: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Agreement: Alternative Selection: Full Name of Authorized Agent: Email of Authorized Agent: Relationship to Corporation of Authorized Agent: City of Residence: County of Residence: State: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Indication:
750 2023-08-20 16:41 Anonymous (not verified) 94.188.207.229 Wonderfully Made LLC 2003 Downing Ave Waterloo IA 50701 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-20 Alexis Lise Martinez victorandleximartinez@gmail.com Waterloo Black Hawk IA Trey Patterson Lauren Shaff Signed (1) The corporation rejects the employers’ liability coverage. Alexis Lise Martinez victorandleximartinez@gmail.com Owner Waterloo Black Hawk IA Trey Patterson Lauren Shaff Signed
749 2023-08-20 16:36 Anonymous (not verified) 94.188.207.225 Wonderfully Made LLC 2003 Downing Ave Waterloo IA 50701 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-20 Víctor Manuel Martinez Jr. martinezvic54@gmail.com Waterloo Black Hawk IA Trey Patterson Lauren Shaff Signed (1) The corporation rejects the employers’ liability coverage. Alexis Lise Martinez victorandleximartinez@gmail.com Owner Waterloo Black Hawk IA Trey Patterson Lauren Shaff Signed
748 2023-08-20 14:18 Anonymous (not verified) 94.188.205.177 NexLevelMoving 1186 capital dr sw I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2023-08-16 Ethan Daniel Sailer ethan.sailer@hscsi.net Cedar Rapids Linn County Iowa Denis Sailer Penny Sailer Signed (2) The corporation declines to reject the employers’ liability coverage. Tarin Erenberger tarin.nexlevelmoving@gmail.com Employee Cedar Rapids Linn County Iowa Taj Barrett Taj Barrett Signed
747 2023-08-19 15:30 Anonymous (not verified) 94.188.207.229 Arneson Tree Service 901 s Washington st Lake Mills IOWA 50450 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-19 Charles Douglas Arneson charles.arneson@aol.com Lake Mills Winnebago IOWA Amber Arneson Carter Arneson Signed (1) The corporation rejects the employers’ liability coverage. Charles Douglas Arneson charles.arneson@aol.com Owner Lake Mills Winnebago IOWA Amber arneson Carter Arneson Signed
746 2023-08-17 11:31 Anonymous (not verified) 94.188.207.225 NIEMEYER WELL AND PUMP INC 2735 GARFIELD AVE, HULL IA 51239 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-15 ELIJAH NIEMEYER PERSONALELINIEMEYER@GMAIL.COM HULL SIOUX IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The corporation rejects the employers’ liability coverage. ELIJAH NIEMEYER PERSONALELINIEMEYER@GMAIL.COM SELF HULL SIOUX IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
745 2023-08-17 11:29 Anonymous (not verified) 94.188.207.226 NIEMEYER WELL AND PUMP INC 2735 GARFIELD AVE, HULL IA 51239 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-11 HAROLD NIEMEYER handmpump@gmail.com FREEMAN HUTCHINSON SD JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The corporation rejects the employers’ liability coverage. HAROLD NIEMEYER handmpump@gmail.com SELF FREEMAN HUTCHINSON SD JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
744 2023-08-17 11:25 Anonymous (not verified) 94.188.207.225 NIEMEYER WELL AND PUMP INC 2735 GARFIELD AVE, HULL IA 51239 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-15 TYLER NIEMEYER neighborhoodpump@gmail.com CANTON LINCOLN SD JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The corporation rejects the employers’ liability coverage. TYLER NIEMEYER neighborhoodpump@gmail.com SELF CANTON LINCOLN SD JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
743 2023-08-15 15:03 Anonymous (not verified) 94.188.205.177 R & T Trucking LLC 1374 Creamery Road, Afton Iowa 50830 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-15 Robert Dike robandteenadike@outlook.com Afton Union Iowa Kristina Dike Robert Dike Signed (1) The corporation rejects the employers’ liability coverage. Robert Dike robandteenadike@outlook.com Owner Afton Union Iowa Kristina Dike Robert Dike Signed
742 2023-08-15 12:06 Anonymous (not verified) 94.188.205.175 The Ritz Restaurant, LLC 232 1st Ave E - Dyersville, IA 52040 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-11 Dan Engstrom jheims@english-insurance.com Dyersville Dubuque IA Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons jheims@english-insurance.com self Dyersville IA IA Joyce Heims Derrick Parsons Signed
741 2023-08-15 12:03 Anonymous (not verified) 94.188.205.176 The Ritz Restaurant, LLC 232 1st Ave E - Dyersville, IA 52040 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-11 Megan Engstrom jheims@english-insurance.com Dyersville Dubuque IA Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons jheims@english-insurance.com self Dyersville DUbuque IA Joyce Heims Derrick Parsons Signed
740 2023-08-14 10:25 Anonymous (not verified) 94.188.205.167 Absolute Mud Jacking Inc 5038 Brittany Ct Bettendorf Iowa 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. 2023-08-12 Paul Pelzer pelzer830@gmail.com Bettendorf IA United States Brett Lewandowski Phil Schaefer Signed (1) The corporation rejects the employers’ liability coverage. Paul Pelzer pelzer830@gmail.com Owner Bettendorf IA United States Brett Lewandowski Phil Schaefer Signed
739 2023-08-11 18:02 Anonymous (not verified) 94.188.205.176 Frontline Roofing & Construction LLC 310 W Gilbert Dr I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2023-08-10 Verónica Santos FrontlineR-C@outlook.com Evansdale BlackHawk County IA Angela Hernandez Kevi Hernandez Signed (2) The corporation declines to reject the employers’ liability coverage. Veronica Santos angelasermeno@gmail.com Owner Evansdale BlackHawk IA Angela Hernandez Signed
738 2023-08-11 08:47 Anonymous (not verified) 94.188.207.223 Infrastructure Engineering, Inc. 1451 NE 69TH PL, Ste 42 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. 2023-08-11 Joel Peiffer peifferj@ieidsm.com Ankeny Polk Iowa Bret Larkins Heather Cornwell Signed (1) The corporation rejects the employers’ liability coverage. Joel Peiffer peifferj@ieidsm.com Owner ANKENY Iowa Iowa Bret Larkins Heather Cornwell Signed
737 2023-08-10 21:39 Anonymous (not verified) 94.188.207.224 fixIT.fyi, LLC 1243 Buchanan Ave, Sioux City, IA 51108 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-10 Daisy Larae Neuroth Daisy@fixIT.fyi Sioux City Woodbury Iowa Chad Neuroth Alice Bruns Signed (1) The corporation rejects the employers’ liability coverage. Daisy Larae Neuroth Daisy@fixIT.fyi Owner/Same Sioux City Woodbury Iowa Chad Neuroth Alice Bruns Signed
736 2023-08-10 11:28 Anonymous (not verified) 94.188.205.169 Johnson Custom Paint & Design 1414 N 9th 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. 2023-08-10 Joshua Johnson johnsoncustompaint@hotmail.com Fort Dodge Webster Iowa Jacklyn Johnson Roger Johnson Signed (1) The corporation rejects the employers’ liability coverage. Joshua Johnson johnsoncustompaint@hotmail.com Owner Fort Dodge Webster Iowa Jacklyn Johnson Roger Johnson Signed
735 2023-08-10 08:07 Anonymous (not verified) 94.188.205.166 GIBSON CLOVER HOUSE LLC 601 South roosevelt suite 101 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-10 Zacary Richard Gayewski zgay187@outlook.com BURLINGTON Des Moines Iowa John Jacob gayewski Derek Wayne Shipley Signed (1) The corporation rejects the employers’ liability coverage. John Jacob Gayewski zgay187@outlook.com owner burlington Des Moines Iowa Zacary Richard Gayewski Derek Wayne Shipley Signed
734 2023-08-09 10:33 Anonymous (not verified) 94.188.207.227 Atcher Service LLC 145 Fremont Street, Hartford, IA 50118 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-08 Mandalena K Love dlovem2002@gmail.com Hartford Warren Iowa Dan Love Michael Love Signed (1) The corporation rejects the employers’ liability coverage. Daniel J Love atcherservicetowing@gmail.com owner Hartford Warren Iowa Dan Love Michael Love Signed
733 2023-08-09 10:22 Anonymous (not verified) 94.188.207.230 Atcher Service LLC 145 Fremont Street, Hartford, IA 50118 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-08 Daniel J Love atcherservicetowing@gmail.com Hartford Warren Iowa Mandy Love Michael Love Signed (1) The corporation rejects the employers’ liability coverage. Mandy Love dlovem2002@gmail.com owner Hartford Warren Iowa Dan Love Michael Love Signed
732 2023-08-07 10:04 Anonymous (not verified) 94.188.207.223 Troy Neville 3647 Dean Ave. Odebolt, IA 51458 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-07 Troy Leslie Neville neville@schallertel.net Odebolt Sac Iowa Joe McCollum Heather Husman Signed (1) The corporation rejects the employers’ liability coverage. Troy Neville neville@schallertel.net onwer Odebolt Sac Iowa Joe McCollum Heather Husman Signed
731 2023-08-04 09:43 Anonymous (not verified) 94.188.207.229 Hopp's Computers & More 855 S. Page St., Nauvoo, IL 62354 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-04 James Hopp tech@hoppcomputers.com Nauvoo Hancock Illinois Carol McGhghy Ana LeVesque Signed (1) The corporation rejects the employers’ liability coverage. James Hopp tech@hoppcomputers.com Owner Nauvoo Hancock Illinois Carol McGhghy Ana LeVesque Signed
730 2023-08-04 07:42 Anonymous (not verified) 94.188.207.225 Barrel Head Winery Inc 9995 Laudeville Road, Dubuque, IA 52003 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-03 Jodie Fuhreck sales@barrelheadiowa.com Dubuque Dubuque Iowa Derrick Parsons Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Jodie Fuhreck sales@barrelheadiowa.com Owner Dubuque Dubuque Iowa Derrick Parsons Derrick Parsons Signed
729 2023-08-04 07:39 Anonymous (not verified) 94.188.207.228 Barrel Head Winery Inc 9995 Laudeville Road, Dubuque, IA 52003 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-03 Aaron Fuhreck sales@barrelheadiowa.com Dubuque Dubuque Iowa Derrick Parsons Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Aaron Fuhreck sales@barrelheadiowa.com Owner Dubuque Dubuque Iowa Derrick Parsons Derrick Parsons Signed
728 2023-08-03 12:28 Anonymous (not verified) 94.188.205.166 Advanced Plumbing LLC 2538 Carbide Ln, 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. 2023-08-03 James O'Shea advancedplumbing1@yahoo.com Keokuk Iowa United States Rebecca O'Shea Tate O'Shea Signed (1) The corporation rejects the employers’ liability coverage. James O'Shea advancedplumbing1@yahoo.com Partner Keokuk Iowa United States Rebecca O'Shea Tate O'Shea Signed
727 2023-08-02 18:25 Anonymous (not verified) 94.188.205.176 Furever Friends Rescue of Appanoose, Inc 19507 Hwy 2, Centerville, Iowa 52544 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-02 Krystal Fowler krystalfowler@gmail.com Cincinnati Appanoose Iowa Jennifer Appler Kimberly Stonehouse Signed (1) The corporation rejects the employers’ liability coverage. Krystal Fowler krystalfowler@gmail.com Treasurer Cincinnati Appanoose Iowa Jennifer Appler Kim Stonehouse Signed
726 2023-08-02 17:30 Anonymous (not verified) 94.188.205.169 Furever Friends of Appanoose, Inc 19507 Hwy 2, Centerville, Iowa 52544 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-02 Clint Raymond Housh clinthoush@lockridgeinc.com Centerville Appanoose Iowa Brian Seeman Drew Power Signed (1) The corporation rejects the employers’ liability coverage. Clint Housh clinthoush@lockridgeinc.com Vice President Centerville Appanoose Iowa Brian Seeman Drew Power Signed
725 2023-08-02 17:25 Anonymous (not verified) 94.188.207.225 Furever Friends Rescue of Appanoose, Inc 19507 Hwy 2, Centerville, Iowa 52544 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-02 Dustin Cain Bozwell dcbozwell@gmail.com Centerville Appanoose Iowa Kimberly Stonehouse Jennifer Appler Signed (1) The corporation rejects the employers’ liability coverage. Dustin Bozwell dcbozwell@gmail.com President Centerville Appanoose Iowa Kimberly Stonehouse Jennifer Appler Signed
724 2023-08-02 16:09 Anonymous (not verified) 94.188.207.223 Magnussen Bros Inc 1945 560th Street, Newell, IA 50568 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-02 Duane Magnussen dcmag@ncn.net Newell Buena Vista Iowa Jared Brashears Katie Gunkelman Signed (1) The corporation rejects the employers’ liability coverage. Duane Magnussen ncmag@ncn.net Owner Newell Buena Vista IA Jared Brashears Katie Gunkelman Signed
723 2023-08-01 15:37 Anonymous (not verified) 94.188.205.169 Flow Media, Inc 1710 Wenig Rd NE I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-01 Courtney Tabelisma Ball courtney@flowmedia.com Cedar Rapids IA United States Hannah Jane White Gregory Michael White Signed (1) The corporation rejects the employers’ liability coverage. Courtney Tabelisma Ball courtney@flowmedia.com Owner Cedar Rapids Linn Iowa Sonya Catherine Geenen Gregory Michael White Signed
722 2023-08-01 11:55 Anonymous (not verified) 94.188.207.229 SM TILE DESIGN LLC 670 Daybreak dr I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-01 Samir Mulalic smtiledesign@gmail.com Waukee Iowa United States Samir Mulalic Saneta Dzankovic Signed (1) The corporation rejects the employers’ liability coverage. Samir Mulalic smtiledesign@gmail.com Owner Waukee Iowa United States Samir Mulalic Saneta Dzankovic Signed
721 2023-08-01 09:24 Anonymous (not verified) 94.188.205.167 Dryseal Roofing and Construction 390 Olive St Martensdale, IA 50160 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-01 Travis Tibbits travistibbits@yahoo.com Martensdale Warren IA Hannah Marie Tibbits Chad David Walker Signed (1) The corporation rejects the employers’ liability coverage. Dawn Marie Tibbits Tibbits6@gmail.com Spouse Martensdale Warren IA Hannah Marie Tibbits Chad David Walker Signed
720 2023-07-31 16:01 Anonymous (not verified) 94.188.205.167 Krupa-1 LLC 128 Main 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. 2023-07-31 Maher Patel deckerhotel008@gmail.com Dodgeville Iowa WI Mitch Schaller Susan Cox Signed (2) The corporation declines to reject the employers’ liability coverage. Mihir Patel deckerhotel008@gmail.com Owner/ Partner Fitchberg Dane WI Susan Cox Mitch Schaller Signed
719 2023-07-31 16:00 Anonymous (not verified) 94.188.205.175 Krupa-1 LLC 128 Main 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. 2023-07-31 Maher Patel deckerhotel008@gmail.com Dodgeville Iowa WI Mitch Schaller Susan Cox Signed (2) The corporation declines to reject the employers’ liability coverage. Mihir Patel deckerhotel008@gmail.com Owner/ Partner Fitchberg Dane WI Susan Cox Mitch Schaller Signed
718 2023-07-27 08:43 Anonymous (not verified) 94.188.207.225 HT&T Drywall 479 Old Lincoln Hwy I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-27 Tracy Spray tspray9@hotmail.com Mechanicsville Cedar Iowa Dillon Williams Leighton Raplinger Signed (1) The corporation rejects the employers’ liability coverage. Tracy Spray tspray9@hotmail.com Owner Mechanicsville Cedar Iowa Dillon Williams Leighton Raplinger Signed
717 2023-07-26 11:31 Anonymous (not verified) 94.188.207.230 Lampe Appliance Service, Inc 210 29th St NE, Cedar Rapids, IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-26 Jared Joshua Lampe lampeappliance@gmail.com CEDAR RAPIDS Linn Iowa Douglas James Lampe John Kenneth Lampe Signed (1) The corporation rejects the employers’ liability coverage. Douglas James Lampe lampeappliance@gmail.com President CEDAR RAPIDS Linn United States John Kenneth Lampe Jared Joshua Lampe Signed
716 2023-07-26 11:27 Anonymous (not verified) 94.188.207.228 Lampe Appliance Service, Inc 210 29th St NE, Cedar Rapids, IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-26 John Kenneth Lampe lampeappliance@gmail.com CEDAR RAPIDS Linn Iowa Douglas James Lampe Jared Joshua Lampe Signed (1) The corporation rejects the employers’ liability coverage. Douglas James Lampe lampeappliance@gmail.com President CEDAR RAPIDS IA United States John Kenneth Lampe Jared Joshua Lampe Signed
715 2023-07-26 11:23 Anonymous (not verified) 94.188.207.226 Lampe Appliance Service, Inc 210 29th St NE, Cedar Rapids, IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-26 Douglas James Lampe lampeappliance@gmail.com Cedar Rapids Linn IA John Kenneth Lampe Jared Joshua Lampe Signed (1) The corporation rejects the employers’ liability coverage. Douglas James Lampe lampeappliance@gmail.com President CEDAR RAPIDS IA United States John Kenneth Lampe Jared Joshua Lampe Signed
714 2023-07-25 16:16 Anonymous (not verified) 94.188.207.224 Midwest Systems 2877 130th St Aurora, Ia 50607 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-25 Matt Griswold midwestsystems@live.com Aurora IA United States Creatleigh Griswold Carslyn Griswold Signed (1) The corporation rejects the employers’ liability coverage. Matt Griswold midwestsystems@live.com Owner Aurora IA United States Creatleigh Griswold Carslyn Griswold Signed
713 2023-07-25 12:26 Anonymous (not verified) 94.188.205.174 HT&T Drywall 479 old lincoln hwy Mechanicsville Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-25 Tracy Spray tspray9@hotmail.com Mechanicsville Cedar Iowa Dillon Williams Leighton Raplinger Signed (1) The corporation rejects the employers’ liability coverage. Tracy Spray tspray9@hotmail.com Owner Mechanicsville Cedar Iowa Dillon Williams Leighton Raplinger Signed
712 2023-07-24 12:34 Anonymous (not verified) 94.188.205.168 BOG Roofing 3768 Deerbrook Dr I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-24 Devon Booton devonboot1973@gmail.com Bettendorf Iowa United States Viviana Gonzalez Shannon Wolever Signed (1) The corporation rejects the employers’ liability coverage. Devon Booton devonboot1973@gmail.com Self Bettendorf Iowa United States Viviana Gonzalez Shannon Wolever Signed
711 2023-07-24 12:04 Anonymous (not verified) 94.188.205.176 HAIGH & ESPE LIMITED 1198 GRAND AVE, MARION, IA 52302 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-24 LYNN M. HAIGH ADAMSTILEANDSTONE@GMAIL.COM Cedar Rapids Linn Iowa DAVID REIBSAMEN STACEY ROGERS Signed (1) The corporation rejects the employers’ liability coverage. LYNN M. HAIGH ADAMSTILEANDSTONE@GMAIL.COM CORP. SECRETARY CEDAR RAPIDS LINN IOWA DAVID REIBSAMEN STACEY ROGERS Signed
710 2023-07-21 08:26 Anonymous (not verified) 94.188.205.169 Dream Team Anesthesia, Inc. 2800 E. Enterprise Ave, Ste 333, Appleton, WI 54913 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-21 Jesse Chiu jessechiu2@yahoo.com Sterling Whiteside IL Joseph Chiu Kin Chiu Signed (1) The corporation rejects the employers’ liability coverage. Jesse Chiu jessechiu2@yahoo.com President Waterloo Polk Iowa Joseph Chiu Kin Chiu Signed
709 2023-07-17 15:46 Anonymous (not verified) 94.188.205.166 Breuer Roofing Company 3021 Sunburst Dr. 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. 2023-07-17 Chad Breuer chadbreuer@gmail.com Bettendorf Scott IA Caroline Kristina Breuer Patricia Ann Breuer Signed (1) The corporation rejects the employers’ liability coverage. Chad Michael Breuer chadbreuer@gmail.com President Bettendorf Scott IA Caroline Kristina Breuer Patricia Ann Breuer Signed
708 2023-07-14 09:24 Anonymous (not verified) 94.188.205.166 Ellis Flying Service Inc. 6550 HWY 17 South Newport AR 72112 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-14 Mark Ellis fly@ellisflying.com Newport Arkansas United States Alex Webb Becky Ellis Signed (1) The corporation rejects the employers’ liability coverage. Mark A Ellis fly@ellisflying.com President Newport Arkansas United States Alex Webb Becky Ellis Signed
707 2023-07-10 12:50 Anonymous (not verified) 94.188.207.228 Gaytán Framing 5303 Brook Landing Cir Des Moines Ia 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. 2023-07-10 Jose Gaytán Ruiz pedro.j.zelaya@gmail.com Des moines Polk Iowa Pedro zelaya Yeraldi Nabor Signed (1) The corporation rejects the employers’ liability coverage. Jose Gaytán Ruiz pedro.j.zelaya@gmail.com Owner Des moines Polk Iowa Pedro Zelaya Yeraldi nabor Signed
706 2023-07-06 17:45 Anonymous (not verified) 94.188.207.230 Gaytán Framing 5303 Brook landing cir 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. 2023-07-06 Jose Gaytán Ruiz jose1988.jg8@gmail.com Des moines Polk Iowa Pedro zelaya Yeraldi nabor Signed (1) The corporation rejects the employers’ liability coverage. Jose Gaytán Ruiz jose1988.jg8@gmail.com Owner Des Moines Polk Iowa Pedro zelaya Yeraldi Nabor Signed
705 2023-07-06 14:24 Anonymous (not verified) 94.188.205.167 Portwood H3D Consulting 1109 295th Street, Oxford Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-06 Brian Portwood portwoodh3dconsulting@gmail.com Oxford Johnson Iowa Bob Herring Chelsey Atkinson Signed (1) The corporation rejects the employers’ liability coverage. Brian Portwood portwoodh3dconsulting@gmail.com owner Oxford Johnson Iowa Bob Herring Chelsey Atkinson Signed
704 2023-06-30 11:09 Anonymous (not verified) 94.188.205.174 KLS Meter Services, LLC 1000 Woodbury Council Bluffs IA 51503 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-29 Kevin Schrage kls2021@yahoo.com Council Bluffs Pottawattamie IA Stephan Nelson Miriam Martinez Signed (1) The corporation rejects the employers’ liability coverage. David E Pike Stephan@pikeinsuranceservices.com Broker Oceanside California CA Stephan Nelson Miriam Martinez Signed
703 2023-06-27 07:05 Anonymous (not verified) 94.188.207.229 Dancom Inc 1001 Office Park Rd, West Des Moines, IA 50265 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-26 Calvin Otundo calvin@dancoms.com Waukee Polk IA Joe Meyers Robert Simmons Signed (1) The corporation rejects the employers’ liability coverage. Calvin Otundo calvin@dancoms.com Owner Waukee Polk IA Robert Simmons Joe Meyers Signed
702 2023-06-27 07:04 Anonymous (not verified) 94.188.207.230 Dancom Inc 1001 Office Park Rd, West Des Moines, IA 50265 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-26 Daniel Otundo daniel@dancoms.com Waukee Polk IA Joe Meyers Robert Simmons Signed (1) The corporation rejects the employers’ liability coverage. Daniel Otundo daniel@dancoms.com Owner Waukee Polk IA Robert Simmons Joe Meyers Signed
701 2023-06-22 15:06 Anonymous (not verified) 94.188.205.166 Des Moines Contractors 833 Buchanan 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. 2023-06-22 Maison Wayne Miller DesMoinesContractors@gmail.com Des Moines Polk Iowa Kent Sorenson Krista Sheriff Signed (1) The corporation rejects the employers’ liability coverage. Maison Wayne Miller DesMoinescontractors@gmail.com Owner Des moines IA United States Kent Sorenson Krista Sheriff Signed