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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:
345 2021-10-11 15:36 Anonymous (not verified) 173.188.10.36 Outdoor Pros LLC 4525 HWY 22 SE I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-10-11 Erik Scott Alberhasky erikalberhas@gmail.com LONE TREE IA United States Melanie Hockenson Robin Morrison Signed (1) The corporation rejects the employers’ liability coverage. Erik Scott Alberhasky erikalberhas@gmail.com Owner LONE TREE IA United States Melanie Hockenson Robin Morrison Signed
896 2024-02-23 16:14 Anonymous (not verified) 94.188.205.167 Convenience Stores Business Inc 1615 Bishop Ave, Waterloo, IA 50707 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2025-02-26 John Sarwar trampride@aol.com Waterloo Black Hawk IA . . Signed (1) The corporation rejects the employers’ liability coverage. Jason Koch jason_koch@veridiancu.org Agent Waterloo Black Hawk IA . . Signed
854 2024-01-16 14:59 Anonymous (not verified) 94.188.207.226 AJS Sanitation LLC 504 Locust, St, PO Box 144, Minburn, Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-16 Jason Mash jmash79@yahoo.com Minburn Dallas Iowa Don Richardson Abbey Luellen Signed (1) The corporation rejects the employers’ liability coverage. Jason Mash jmash79@yahoo.com President Minburn Dallas Iowa Don Richardson Abbey Luellen Signed
137 2020-11-23 10:11 Anonymous (not verified) 207.32.14.70 Community Ambulance Service, Inc. 15 N 1st St., Estherville, IA 51334 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-11-18 Christopher Fuhrman christopher.furhrman@edwardjones.com Spirit Lake Dickinson Iowa Sara M Fisher Abbie J Fuhrman Signed (1) The corporation rejects the employers’ liability coverage. Christopher Fuhrman christopher.fuhrman@edwardjones.com President Spirit Lake Dickinson Iowa Sara M Fisher Abbie J Fuhrman Signed
224 2021-03-29 11:26 Anonymous (not verified) 174.198.71.64 Pro wash Dubuque inc 1795 Atlantic st I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-28 Jordan John block prowashdubuque@gmail.com East Dubuque Jo Davis IL Abigail Ann Metcalf Dawn Marie block Signed (1) The corporation rejects the employers’ liability coverage. Ludovissy insurance jeff@ludovissyandassociates.com He is my agent Dubuque Dubuque country IA Jordan John block Abigail Ann Metcalf Signed
610 2023-02-23 16:19 Anonymous (not verified) 94.188.207.228 Glorious tile service llc 3905 NE 6th st Ankeny IA 50021 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2023-02-23 Heileselaisi unguec glorioustile6@gmail.com Ankeny United States IOWA Robert duku Abraham deng Signed (2) The corporation declines to reject the employers’ liability coverage. Heileselaisi unguec glorioustile6@gmail.com Owner llc member Ankeny United States Iowa Robert duku Abraham deng Signed
611 2023-02-23 16:27 Anonymous (not verified) 94.188.207.224 Sandra unguec 3905 NE 6th st Ankeny IA 50021 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2023-02-23 Sandra unguec glorioustile6@gmail.com Ankeny United States Iowa Robert duku Abraham deng Signed (2) The corporation declines to reject the employers’ liability coverage. Sandra unguec glorioustile6@gmail.com Wife of the owner Ankeny United States Iowa Robert duku Abraham deng Signed
555 2022-10-06 17:48 Anonymous (not verified) 67.22.198.94 Baker Irrigation inc 2621 310th st I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-10-08 Daniel Brent Baker dan@bakerirrigationia.com ROCK VALLEY IA United States Adam Kooistra Alex De Jager Signed (1) The corporation rejects the employers’ liability coverage. Daniel Baker dan@bakerirrigationia.com President ROCK VALLEY IA United States Alex DeJager Adam Kooistra Signed
974 2024-05-06 08:02 Anonymous (not verified) 94.188.205.176 Milton Recycling & Roll Off Service LLC 1266 218 PL, Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-06 Glenn Kreuder kreuderfarms@yahoo.com Boone IA United States Amanda Krull Adam Krull Signed (1) The corporation rejects the employers’ liability coverage. Glenn Kreuder kreuderfarms@yahoo.com Member Boone IA United States Amanda Krull Adam Krull Signed
829 2023-11-27 08:59 Anonymous (not verified) 94.188.207.224 Adam Ruess Masonry 206.w Elm st I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-27 Adam Ruess ruess33@gmail.com Lone Tree IA United States Adam Ruess Adam Ruess Signed (1) The corporation rejects the employers’ liability coverage. Adam Ruess ruess33@gmail.com Owner Lone Tree IA United States Adam Ruess Adam Ruess Signed
904 2024-02-28 06:52 Anonymous (not verified) 94.188.205.167 Monarca General Builders LLC. 551 Martin Rd Waterloo Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-28 Antonio Serrato Sánchez assmsaeaj@icloud.com Waterloo Black Hawk Iowa Maria santos Juarez Adan Alvarez Signed (1) The corporation rejects the employers’ liability coverage. Antonio Serrato Sánchez assmsaeaj@icloud.com President Waterloo Black Hawk Iowa Maria santos Juarez Adan Alvarez Signed
905 2024-02-28 11:47 Anonymous (not verified) 94.188.207.228 Monarca General Builders LLC 551 Martin Rd Waterloo Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-01 Antonio Serrato Sánchez assmsaeaj@icloud.com Waterloo Black Hawk Iowa Maria santos Juarez Adan Alvarez Signed (1) The corporation rejects the employers’ liability coverage. Antonio Serrato Sánchez assmsaeaj@icloud.com Presidente Waterloo Black Hawk Iowa Maria santos Juarez Adan Alvarez Signed
669 2023-05-15 09:26 Anonymous (not verified) 94.188.207.229 SOUTHWEST IOWA ELECTRIC LLC 800 NW SPRUCE ST,EARLHAM, IA 50072 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-12 ISAAC NORTON NORTON2412@GMAIL.COM EARLHAM DALLAS IOWA GARRETT ROBINSON ADDILIE NORTON Signed (1) The corporation rejects the employers’ liability coverage. ISAAC NORTON NORTON2412@GMAIL.COM PRESIDENT EARLHAM DALLAS IOWA GARRETT ROBINSON ADDILIE NORTON Signed
858 2024-01-18 08:24 Anonymous (not verified) 94.188.207.226 Custom Flooring LLC 7085 Bloomfield Road Lot 249 Des Moines, Iowa 50320 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-18 Jesus Vera jesusvera199027@icloud.com Des Moines Polk Iowa Natalia Vera Adriana de Anda Signed (1) The corporation rejects the employers’ liability coverage. Jesus Vera jesusvera199027@icloud.com Owner Des Moines Polk Iowa Natalia Vera Adriana de Anda Signed
456 2022-04-29 08:14 Anonymous (not verified) 107.126.24.57 Thatcher Auto Center INC 406 S West Ave. Baxter, IA 50028 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-01 Matthew Lee Wells Praynostop@msn.com Des Moines Polk Iowa Joel Schabilion Al Nuzum Signed (1) The corporation rejects the employers’ liability coverage. Rick Thatcher rickswrecks@gmail.com President Baxter Jasper Iowa Joel Schabilion Al Nuzum Signed
457 2022-04-29 08:21 Anonymous (not verified) 107.126.24.57 Thatcher Auto Center INC 406 S West ave Baxter, IA 50028 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-01 Nathan Doubek thatcherautocenter@gmail.com Baxter Jasper Iowa Joel Schabilion Al Nuzum Signed (1) The corporation rejects the employers’ liability coverage. Rick Thatcher rickswrecks@gmail.com President Baxter Jasper Iowa Joel Schabilion Al Nuzum Signed
458 2022-04-29 08:26 Anonymous (not verified) 107.126.24.57 Thatcher Auto Center INC 406 S West ave Baxter Iowa 50028 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-01 Richard Thatcher rickswrecks@gmail.com Baxter Jasper Iowa Joel Schabilion Al Nuzum Signed (1) The corporation rejects the employers’ liability coverage. Nathan Doubek thatcherautocenter@gmail.com Vice President Baxter Jasper Iowa Joel Schabilion Al Nuzum Signed
459 2022-04-29 08:49 Anonymous (not verified) 107.126.24.57 Thatcher Auto Center INC 406 S West ave Baxter. IA 50028 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-15 David Kirkman kirkcola@gmail.com Newton Jasper Iowa Joel Schabilion Al Nuzum Signed (1) The corporation rejects the employers’ liability coverage. Rick Thatcher rickswrecks@gmail.com President Baxter Jasper Iowa Joel Schabilion Al Nuzum Signed
492 2022-06-06 20:18 Anonymous (not verified) 69.54.109.51 R C TRUCKING, LTD. 16125 310th Street, Mason City, Iowa 50401 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-06 ROGER CHIZEK joldoak@gmail.com MASON CITY Iowa United States Kathy Zobrist Alan Zobrist Signed (1) The corporation rejects the employers’ liability coverage. ROGER CHIZEK joldoak@gmail.com President MASON CITY Iowa United States Kathy Zobrist Alan Zobrist Signed
43 2020-02-28 09:50 Anonymous (not verified) 173.24.140.77 W R Main Contractor Inc 1620 NW 78th Street, Clive, IA 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-02-28 Cindy Jo Ohmart co4mainco@aol.com West Des Moines Polk Iowa Jill Ann Reber Alane Marguerite Richardson Signed (1) The corporation rejects the employers’ liability coverage. Mark I Main markmain@icloud.com President Waukee Dallas Iowa Jill Ann Reber Alane Marguerite Richardson Signed
794 2023-10-18 08:21 Anonymous (not verified) 94.188.205.177 J&M Tire and Repair 31006 hedge ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-18 Macklin Paul Barkley flyingtank92@yahoo.com merrill Iowa United States Brandon Norris Alex Barkley Signed (1) The corporation rejects the employers’ liability coverage. Macklin Paul Barkley jmtireandrepair@gmail.com Owner sioux city Iowa United States Brandon Norris Alex Barkley Signed
38 2020-02-08 13:16 Anonymous (not verified) 208.126.52.97 Savage Industries Inc 2368 110th street Delmar, ia 52037 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-02-08 Jordan Hicks jjjhicks22@gmail.com Delmar Clinton Iowa Brittany Hicks Alex Laban Signed (1) The corporation rejects the employers’ liability coverage. Jordan Hicks jjjhicks22@gmail.com President Delmar Clinton Iowa Brittany Hicks Alex Laban Signed
252 2021-05-04 13:47 Anonymous (not verified) 159.242.43.24 J. Fox Distributing, Inc 3801 Pierce Street, Sioux City, IA 51104 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-05-04 Joseph Fox huskerjoe12@gmail.com Sioux City Woodbury IA Jenny McIntyre Alex Meier Signed (1) The corporation rejects the employers’ liability coverage. Joseph Fox huskerjoe12@gmail.com President Sioux City Woodbury IA Jenny McIntyre Alex Meier Signed
759 2023-08-31 16:11 Anonymous (not verified) 94.188.207.230 Living Free Ministries 11 2nd St NW, Mason City, IA 50401 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-31 Jani Dahlin livingfreeiowa@gmail.com Mason City Cerro Gordo IA Jenny McIntyre Alex Meier Signed (1) The corporation rejects the employers’ liability coverage. Jani Dahlin livingfreeiowa@gmail.com President Mason City Cerro Gordo IA Jenny McIntyre Alex Meier Signed
939 2024-04-01 11:44 Anonymous (not verified) 94.188.207.228 SFA INC 955 31ST MARION, IA 52302-3788 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-04-01 SARAH FERRETER sarah@sfacpa.com MARION LINN IOWA WILLIE CALDWELL ALEXANDRA BACHMAN Signed (1) The corporation rejects the employers’ liability coverage. WILLIE CALDWELL WILLIE.CALDWELL.B2SH@STATEFARM.COM AGENT CEDAR RAPIDS LINN IOWA WILLIE CALDWELL ALEXANDRA BACHMAN Signed
783 2023-10-06 11:08 Anonymous (not verified) 94.188.207.223 Hawkeye Construction and Snow Removal 3581 Perch Drive SE, Unit C, Iowa City, Iowa 52240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-06 Mark Phelps maintenance@hawkeyecampus.com Iowa City Johnson Iowa Elizabeth Phelps Alexandra Phelps Signed (1) The corporation rejects the employers’ liability coverage. Mark Phelps maintenance@hawkeyecampus.com owner Iowa City Johnson Iowa Elizabeth Phelps Alexandra Phelps Signed
737 2023-08-10 21:39 Anonymous (not verified) 94.188.207.224 fixIT.fyi, LLC 1243 Buchanan Ave, Sioux City, IA 51108 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-10 Daisy Larae Neuroth Daisy@fixIT.fyi Sioux City Woodbury Iowa Chad Neuroth Alice Bruns Signed (1) The corporation rejects the employers’ liability coverage. Daisy Larae Neuroth Daisy@fixIT.fyi Owner/Same Sioux City Woodbury Iowa Chad Neuroth Alice Bruns Signed
346 2021-10-14 13:54 Anonymous (not verified) 75.162.50.106 Dawn's Daycare & Educational Program 360 NW Walnut Ave, Earlham, Iowa 50072 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-10-14 Dawn Lynnete Stonehocker daycare.dawn@gmail.com Earlham Madison Iowa Anne Marie Larson Alison Renae Werts Signed (1) The corporation rejects the employers’ liability coverage. Dawn Lynnette Stonehocker daycare.dawn@gmail.com Self Earlham Madison Iowa Anne Marie Larson Alison Renae Werts Signed
347 2021-10-14 19:28 Anonymous (not verified) 75.162.50.106 Dawn's Daycare 360 NW Walnut Ave Earlham,Iowa 50072 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-10-14 James J Stonehocker j_stonehocker@hotmail.com Earlham Madison iowa Anne Larson Alison Werts Signed (1) The corporation rejects the employers’ liability coverage. James J Stonehocker j_stonehocker@hotmail.com Owner Earlham Madison Iowa Anne Larson Alison Werts Signed
923 2024-03-19 13:53 Anonymous (not verified) 94.188.207.224 Hawki Housing Solutions LLC 5036 Highway 61 Burlington, Iowa 52601 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-19 Kyle Carruthers carruthershunters@gmail.com Burlington Des Moines IOWA Laura Carruthers Allice Smith Signed (1) The corporation rejects the employers’ liability coverage. Kyle Carruthers carruthershunters@gmail.com Owner Burlington Des Moines IOWA Laura Carruthers Allice Smith Signed
20 2019-12-30 09:39 Anonymous (not verified) 207.191.194.182 LA Trends Addict Inc 1200 N CENTER POINT RD I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2019-10-07 Laura Frey fcrentals1@gmail.com HIAWATHA Linn IA Traci Lyons Allie DeVore Signed (1) The corporation rejects the employers’ liability coverage. Laura Frey fcrentals1@gmail.com Owner HIAWATHA Linn IA Traci Lyons Allie DeVore Signed
21 2019-12-30 11:28 Anonymous (not verified) 207.191.194.182 Bob Stephen Motors Inc 324 W Main St, Manchester IA 52057 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2019-11-05 Paul Roussell twyladetrich@gmail.com MANCHESTER DELAWARE IA Traci Lyons Allie DeVore Signed (1) The corporation rejects the employers’ liability coverage. Heidi Roussell twyladetrich@gmail.com Vice President Manchester DELAWARE IA Traci Lyons Allie DeVore Signed
22 2019-12-30 11:30 Anonymous (not verified) 207.191.194.182 Bob Stephen Motors Inc 324 West Main St, Manchester IA 52057 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2019-11-05 Heidi Roussell twyladetrich@gmail.com Manchester DELAWARE IA Traci Lyons Allie DeVore Signed (1) The corporation rejects the employers’ liability coverage. Paul Roussell twyladetrich@gmail.com President MANCHESTER Delaware IA Traci Lyons Allie DeVore Signed
682 2023-06-07 16:10 Anonymous (not verified) 94.188.207.223 Jake's Insulation Inc. 2020 Valley High Dr. Cedar Falls, IA I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-07 Jacob Ryan Smalley jakersmalley@gmail.com Cedar Falls Black Hawk Iowa Emily D Smalley Allison L Smalley Signed (1) The corporation rejects the employers’ liability coverage. Jacob Ryan Smalley jakersmalley@gmail.com President Cedar Falls Black Hawk Iowa Emily Smalley Allison Smalley Signed
230 2021-04-06 21:15 Anonymous (not verified) 173.23.145.187 Jose J Framing 5301 SE 24th St. Des Moines IA 50320 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2021-01-01 Jose J. Castillo castillojosejonathan7@gmail.com Des Moines Polk United States Perla Landaverde Garcia Alma Y. Gaytan Signed (2) The corporation declines to reject the employers’ liability coverage. Jose J. Castillo castillojosejonathan7@gmail.com self Des Moines Polk Iowa Perla Landaverde Garcia Alma Y. Gaytan Signed
362 2021-11-16 11:20 Anonymous (not verified) 63.227.65.43 F&H Aluminum, Inc. 101 E. Corporate Drive Charles City, Iowa 50616 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-11-16 DeWayne Ferch fhaluminum@netconx.net Kensett Worth Iowa Tom Stephany Amanda Korenberg Signed (1) The corporation rejects the employers’ liability coverage. DeWayne Ferch fhaluminum@netconx.net President Kensett Worth Iowa Tom Stephany Amanda Korenberg Signed
594 2023-01-31 09:17 Anonymous (not verified) 70.58.136.161 Great Tree LLC 2701 e douglas ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-31 Robert buell Greattree55@gmail.com Des Moines IA United States Jamarlo alvarez Fields Amanda lee netolicky Signed (1) The corporation rejects the employers’ liability coverage. Robert buell Greattree55@gmail.com ceo/ company owner/ operator Des Moines IA United States Jamarlo Alvarez Fields Amanda Lee Netolicky Signed
840 2023-12-18 16:21 Anonymous (not verified) 94.188.205.166 DC Painting Inc 205 Astor St I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-18 Damion Clement amanda_thompson_marie@yahoo.com Des Moines polk IA Brandi Haight Amanda Thompson Signed (1) The corporation rejects the employers’ liability coverage. Damion Clement amanda_thompson_marie@yahoo.com owner Des Moines Polk IA Brandi Haight Amanda Thompson Signed
841 2023-12-18 16:28 Anonymous (not verified) 94.188.205.168 Dennis Clement 203 Astor St I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-18 Dennis Clement haight0929@gmail.com Des Moines Polk IA Amanda Thompson Brandi Haight Signed (1) The corporation rejects the employers’ liability coverage. Dennis Clement haight0929@gmail.com none Des Moines polk IA Brandi Haight Amanda Thompson Signed
842 2023-12-18 16:31 Anonymous (not verified) 94.188.205.168 Brandon Clement 3503 South Union St I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-18 Brandon Clement hawthornhill@paramark.us Des Moines Polk IA Brandi Haight Amanda Thompson Signed (1) The corporation rejects the employers’ liability coverage. Brandon Clement hawthornhill@paramark.us none Des Moines polk IA Brandi Haight Amanda Thompson Signed
418 2022-03-03 14:29 Anonymous (not verified) 72.255.79.18 Ostafi Communication Inc. 2121 Swan Dr. Camanche, IA 52730 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-03 Eduard Ostafi ostaficommunication@gmail.com Camanche Clinton IA Stephanie Millage Amanda Van Theemsche Signed (1) The corporation rejects the employers’ liability coverage. Eduard Ostafi ostaficommunication@gmail.com President Camanche Clinton IA Stephanie Millage Amanda Van Theemsche Signed
385 2022-01-11 08:27 Anonymous (not verified) 173.29.238.103 Brilliant All-Seasons Lighting Inc. 10357 NW 42nd St., Polk City, IA 50226 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-11 Bradley Harold Loney bloney@live.com Polk City Polk Iowa Linda Delin Amanda Warywoda Signed (2) The corporation declines to reject the employers’ liability coverage. Katrina Loney katrinaloney@outlook.com Vice President Polk City Polk Iowa Linda Delin Amanda Warywoda Signed
386 2022-01-11 08:30 Anonymous (not verified) 173.29.238.103 Brilliant All-Seasons Lighting Inc. 10357 NW 42nd St., Polk City, IA 50226 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2022-01-11 Katrina Marie Loney katrinaloney@outlook.com Polk City Polk Iowa Linda Delin Amanda Warywoda Signed (2) The corporation declines to reject the employers’ liability coverage. Brad Loney bloney@live.com President Polk City Polk Iowa Linda Delin Amanda Warywoda Signed
270 2021-06-01 15:39 Anonymous (not verified) 206.72.14.249 TCS Fabricating, Inc 315 Hwy 22 Keswick, IA 50136 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-05-21 Lisa Sieren TCSFAB@NETINS.NET Keswick Keokuk Iowa Scott Grimm Amber Kephart Signed (1) The corporation rejects the employers’ liability coverage. Lisa Sieren TCSFAB@NETINS.NET President Keswick Keokuk Iowa Scott Grimm Amber Kephart Signed
271 2021-06-01 15:39 Anonymous (not verified) 206.72.14.249 TCS Fabricating, Inc 315 Hwy 22 Keswick, IA 50136 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-05-21 Tom Sieren TCSFAB@NETINS.NET Keswick Keokuk Iowa Scott Grimm Amber Kephart Signed (1) The corporation rejects the employers’ liability coverage. Tom Sieren TCSFAB@NETINS.NET Vice President Keswick Keokuk Iowa Scott Grimm Amber Kephart Signed
281 2021-06-30 10:59 Anonymous (not verified) 206.72.14.249 TCS Fabricating, Inc 315 Hwy 22 Keswick, IA 50136 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-06-30 Tom Sieren TCSFAB@NETINS.NET Keswick Keokuk Iowa Scott Grimm Amber Kephart Signed (1) The corporation rejects the employers’ liability coverage. Tom Sieren TCSFAB@NETINS.NET Vice President Keswick IA United States Scott Grimm Amber Kephart Signed
179 2021-02-16 18:03 Anonymous (not verified) 216.248.123.206 Outer Edge Screen Printing 2449 68th Street Van Horne, Iowa 52346 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-02-16 Kyle Christopher Kline outedgekim@gmail.com Van Horne IA United States Kelsea Marie Kline Amber Marie Valentine Signed (1) The corporation rejects the employers’ liability coverage. Kimberly Sue Kline outedgekim@gmail.com spouse Van Horne IA United States Kelsea Marie Kline Amber Lynn Valentine Signed
635 2023-03-23 15:43 Anonymous (not verified) 94.188.207.228 Pacifica Health Services, LLC 4911 SW 19th St, Des Moines, IA 50315 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-23 Kevin Babb kbabb@viahealthservices.com Waukee Dallas Iowa Jackie Hastings Amber Perdue Signed (1) The corporation rejects the employers’ liability coverage. Jennifer Conner jconner@viahealthservices.com President Des Moines Polk IA Jackie Hastings Amber Perdue Signed
636 2023-03-23 15:49 Anonymous (not verified) 94.188.207.229 Pacifica Health Services, LLC 4911 SW 19th St, Des Moines, IA 50315 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-23 Robert Conner dr.conner@metrogeriatrics.com Norwalk Warren Iowa Jackie Hastings Amber Perdue Signed (1) The corporation rejects the employers’ liability coverage. Jennifer Conner jconner@viahealthservices.com President Des Moines Polk IA Jackie Hastings Amber Perdue Signed
637 2023-03-23 15:53 Anonymous (not verified) 94.188.207.229 Pacifica Health Services, LLC 4911 SW 19th St, Des Moines, IA 50315 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-23 Jennifer Conner jconner@viahealthservices.com Des Moines Polk IA Jackie Hastings Amber Perdue Signed (1) The corporation rejects the employers’ liability coverage. Kevin Babb kbabb@viahealthservices.com CEO Waukee Dallas IA Jackie Hastings Amber Perdue Signed
199 2021-03-03 17:32 Anonymous (not verified) 172.58.86.222 Mike Underdahl 1536 W Locust St I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-03 Mike Underdahl mwunderdahl1974@gmail.com Davenport Scott Iowa Phillip Gerald Hoxsey Amee Ann Pepperson Signed (1) The corporation rejects the employers’ liability coverage. Michael Wayne Underdahl mwunderdahl1974@gmail.com Self Davenport Scott Iowa Phillip Gerald Hoxsey Amme Ann Pepperson Signed
277 2021-06-17 21:34 Anonymous (not verified) 97.125.98.166 J. Bos Holdings 10925 NE 23rd Ave Mitchellville, IA 50169 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-06-17 Jeff Bos jeffbos1967@gmail.com Mitchellville Iowa United States Angela Bos Amy Bos Signed (1) The corporation rejects the employers’ liability coverage. Jeff Bos jeffbos1967@gmail.com officer Mitchellville Iowa United States Angela Bos Amy Bos Signed
176 2021-02-03 15:02 Anonymous (not verified) 174.198.90.166 Jesse's Embers LLC 3301 Ingersoll Ave, Des Moines, IA, 50312 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-02-03 Deena Edelstein dledelstein@hotmail.com Des Moines Polk Iowa Eliott Milakovich Amy Jones Signed (2) The corporation declines to reject the employers’ liability coverage. Deena Edelstein dledelstein@hotmail.com Owner Des Moines Polk Iowa Eliott Milakovich Amy Jones Signed
177 2021-02-03 15:07 Anonymous (not verified) 174.198.90.166 Jesse's Embers LLC 3301 Ingersoll Ave, Des Moines, IA, 50312 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-02-03 Martin Scarpino martyscarpino@yahoo.com Des Moines Polk Iowa Eliott Milakovich Amy Jones Signed (2) The corporation declines to reject the employers’ liability coverage. Martin Scarpino martyscarpino@yahoo.com Owner Des Moines IA Iowa Eliott Milakovich Amy Jones Signed
152 2021-01-04 12:08 Anonymous (not verified) 104.129.206.120 Schleswig Transfer Inc 216 Valley View Dr, Schleswig, IA 51461 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-11-30 Wade Miller t.uhl3@joemorten.com Schleswig Crawford Iowa Tamara Uhl Amy Meseck Signed (1) The corporation rejects the employers’ liability coverage. Wade Miller t.uhl3@joemorten.com President Schleswig Crawford IA Tamara Uhl Amy Meseck Signed
426 2022-03-22 12:06 Anonymous (not verified) 69.54.105.130 Downing Development, Ltd. 13004 NW 44th St Polk City, IA 50226 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-22 Carolyn Suzanne Downing susiedowningdevelopment@gmail.com Polk City IA United States Geneva Aki Ross Amy Sue Romero Signed (1) The corporation rejects the employers’ liability coverage. Carolyn Suzanne Downing susiedowningdevelopment@gmail.com Secretary Polk City Polk County Iowa Geneva Aki Ross Amy Sue Romero Signed
427 2022-03-22 12:08 Anonymous (not verified) 69.54.105.130 Downing Development, Ltd. 13004 NW 44th St Polk City, IA 50226 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-22 Steven Jeffrey Downing stevedowningdevelopment@gmail.com Polk City Polk County Iowa Geneva Aki Ross Amy Sue Romero Signed (1) The corporation rejects the employers’ liability coverage. Steven Jeffrey Downing stevedowningdevelopment@gmail.com President Polk City Polk County Iowa Geneva Aki Ross Amy Sue Romero Signed
685 2023-06-15 12:30 Anonymous (not verified) 94.188.205.168 Des Moines Marble & Mantel Co. Inc. 1507 Ohio Street Des Moines, IA 50314 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-15 Benjamin Campos Rojas caya05rojas@gmail.com Des Moines Polk county Iowa Erica Antonio Maya Ana Antonio Maya Signed (1) The corporation rejects the employers’ liability coverage. Mario DeMarco sandyatdmmarble@aol.com Owner Des Moines Polk County Iowa Erica Antonio Maya Ana Antonio Maya Signed
687 2023-06-16 07:59 Anonymous (not verified) 94.188.207.230 Benjamin Campos Rojas 4024 52nd Street Des Moines, Iowa 50310 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-16 Benjamin Campos Rojas caya05rojas@gmail.com Des Moines Polk Iowa Erica Antonio Maya Ana Antonio Maya Signed (1) The corporation rejects the employers’ liability coverage. Benjamin Campos Rojas caya05rojas@gmail.com Owner Des Moines Polk Iowa Erica Antonio Maya Ana Antonio Maya Signed
731 2023-08-04 09:43 Anonymous (not verified) 94.188.207.229 Hopp's Computers & More 855 S. Page St., Nauvoo, IL 62354 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-04 James Hopp tech@hoppcomputers.com Nauvoo Hancock Illinois Carol McGhghy Ana LeVesque Signed (1) The corporation rejects the employers’ liability coverage. James Hopp tech@hoppcomputers.com Owner Nauvoo Hancock Illinois Carol McGhghy Ana LeVesque Signed
857 2024-01-17 16:04 Anonymous (not verified) 94.188.205.167 GA Drywall LLC 1906 West State Street Marshalltown Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-17 Oscar Vazquez LOPEZ gadrywall7@icloud.com Marshalltown Marshall Iowa Ana Ibarra Ana Lopez Signed (1) The corporation rejects the employers’ liability coverage. Oscar Vazquez Lopez oscarlopez177@icloud.com Owner Marshalltown Marshall Iowa Ana Ibarra Ana Lopez Signed
876 2024-01-30 17:55 Anonymous (not verified) 94.188.207.230 Erik Mortens 9823 nw 46th ct polk city iowa 50226 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-30 Erik mortens Erik.mortens@gmail.com Polk city Polk Iowa Andrea Davis Kali Davis Signed (1) The corporation rejects the employers’ liability coverage. Erik mortens Erik.mortens@gmail.com Self Polk city Polk Iowa Kali Davis Andrea Davis Signed
877 2024-01-30 17:58 Anonymous (not verified) 94.188.207.230 Erik Mortens 9823 nw 46th ct polk city iowa 50226 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-30 Steffanie Mortens steffanie.mortens@gmail.com Polk city Polk Iowa Andrea Davis Kali Davis Signed (1) The corporation rejects the employers’ liability coverage. Erik mortens Erik.mortens@gmail.com Self Polk city Polk Iowa Kali Davis Andrea Davis Signed
420 2022-03-04 13:58 Anonymous (not verified) 209.180.36.109 Sani Enterprise LLC 101 Ashworth Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-04 Mustafa Keserovic MustafaKeserovic@gmail.com Ankeny Pokl Iowa Sandro Tadic Andrew Swanson Signed (1) The corporation rejects the employers’ liability coverage. Sandro Tadic sanienterprise14@gmail.com Owner WEST DES MOINES Iowa United States Sandro Tadic Andrew swanson Signed
503 2022-06-30 17:15 Anonymous (not verified) 209.180.36.109 Sani Enterprise 101 Ashworth Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-30 Nexhat Krasniqi nexhat_80@hotmail.com WEST DES MOINES polk Iowa Sandro Tadic Andy Swanson Signed (1) The corporation rejects the employers’ liability coverage. Sandro Tadic sanienterprise14@gmail.com Owner Urbandale Polk Iowa Sandro Tadic Andy Swanson Signed
504 2022-06-30 17:18 Anonymous (not verified) 209.180.36.109 Sani Enterprise 101 Ashworth Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-30 Timothy Roberts roberts.timoty2@gmail.com Des Moines Polk Iowa Sandro Tadic Andy Swanson Signed (1) The corporation rejects the employers’ liability coverage. Sandro Tadic sanienterprise14@gmail.com Owner Urbandale polk iowa Sandro Tadic Andy Swanson Signed
505 2022-06-30 17:20 Anonymous (not verified) 209.180.36.109 Sani Enterprise 101 Ashworth Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-30 Admir Dogic adoydogic@gmail.com Urbandale polk iowa Sandro Tadic Andy Swanson Signed (2) The corporation declines to reject the employers’ liability coverage. Sandro Tadic sanienterprise14@gmail.com Owner Urbandale polk iowa Sandro Tadic Andy Swanson Signed
506 2022-06-30 17:23 Anonymous (not verified) 209.180.36.109 Sani Enterprise 101 Ashworth Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-30 Nada Krasniqi najstor406@gmail.com Johnston Polk iowa Sandro Tadic Andy Swanson Signed (1) The corporation rejects the employers’ liability coverage. Sandro Tadic sanienterprise14@gmail.com Owner Urbandale polk iowa sandro tadic andy swanson Signed
507 2022-06-30 17:25 Anonymous (not verified) 209.180.36.109 Sani Enterprise 101 Ashworth Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-30 Julia hernandez juliaherdz.1983@gmail.com Des Moines polk iowa Sandro Tadic Andy Swanson Signed (1) The corporation rejects the employers’ liability coverage. Sandro Tadic sanienterprise14@gmail.com Owner Urbandale polk iowa sandro tadic andy swanson Signed
991 2024-05-16 11:50 Anonymous (not verified) 94.188.207.229 NSG, LLC 2935 Highway 18, Dickens, IA 51333 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-16 Rosemary G Norgaard rosemary@norgaardllc.com Dickens Clay United States Dan Claus Ange Claus Signed (1) The corporation rejects the employers’ liability coverage. Rosemary G Norgaard rosemary@norgaardllc.com MEMBER Dickens Clay United States Dan Claus Ange Claus Signed
339 2021-09-29 16:59 Anonymous (not verified) 69.57.16.37 MC5 CONSTRUCTION INC 1186 TEXAS AVE, LU VERNE, IOWA 50560 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-18 JOSEPH MCDERMOTT joe.mc5construction@gmail.com LU VERNE HUMBOLDT IOWA NICHOLAS GARMAN ANGELA GARMAN Signed (1) The corporation rejects the employers’ liability coverage. JOSEPH MCDERMOTT joe.mc5construction@gmail.com OWNER LU VERNE HUMBOLDT IOWA NICHOLAS GARMAN ANGELA GARMAN Signed
476 2022-05-19 11:45 Anonymous (not verified) 172.86.13.54 BOLT HOLDINGS Inc. and Holt Precision dba Holt Bladeworks and Holt Kinetic Solutions 3230 N. Center Point Rd Unit 204, Marion, IA 52302 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-19 Joseph Holt Joe@kineticsolutons.com Robins Linn Iowa Lisa Gleason Danielle Congleton Signed (1) The corporation rejects the employers’ liability coverage. Lisa Gleason Lisa@holtkineticsolutions.com General Manager Marion Linn Iowa Danielle Congleton Angey Holt Signed
410 2022-02-20 19:10 Anonymous (not verified) 173.27.233.68 A and W marble and tile Inc 207 Philip St. Des Moines, Iowa 50315 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-20 Wayne Yergy wyergy@gmail.com Des Moines Polk Iowa John Noga Angie Carter Signed (1) The corporation rejects the employers’ liability coverage. Wayne A Yergy wyergy@gmail.com Vice President Des Moines IA United States John Noga Angie Carter Signed
551 2022-10-02 10:56 Anonymous (not verified) 174.198.70.237 Des Moines Roofing Contractor 2234 Highland St Des Moines, IA I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-10-02 Nancy Lopez nanoran3@gmail.com Des Moines Polk City IA Noe Ordaz Angie Florian Signed (1) The corporation rejects the employers’ liability coverage. Nancy Lopez nanoran3@gmail.com Owner Des Moines Polk Iowa Noe Ordaz Angie Florian Signed
880 2024-02-04 18:45 Anonymous (not verified) 94.188.205.176 One Call Exteriors 1928 9th St Des Moines IA 50314 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-04 Nancy López onecallexteriors@gmail.com Des Moines Polk IA Noé Ordaz Angie Florian Signed (1) The corporation rejects the employers’ liability coverage. Nancy López onecallexteriors@gmail.com Owner Des Moines Polk IA Noé Ordaz Angie Florian Signed
927 2024-03-20 23:27 Anonymous (not verified) 94.188.205.177 RRB, LLC 4444 1st Ave NE Ste 510 Cedar Rapids, IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-20 Kelli Holton kelli@rebelroseboutique.co Coralville IA United States Dave Booth Ann Holton Signed (1) The corporation rejects the employers’ liability coverage. Kelli Holton kelli@rebelroseboutique.co Owner Coralville IA United States Dave Booth Ann Holton Signed
641 2023-03-29 08:15 Anonymous (not verified) 94.188.205.175 THERMOGRAPHIC Wellness 1000 N. West St, Suite 1200, Wilmington, DE 19801 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-29 Palmer Piana pianapal@gmail.com Davenport Scott County Iowa Olivia Piana Anthony Piana Signed (1) The corporation rejects the employers’ liability coverage. Olivia Piana joinbti@gmail.com VP of Operations Davenport Scott county IA Palmer Piana Anthony Piana Signed
863 2024-01-23 13:59 Anonymous (not verified) 94.188.205.176 United Marble & Tile, Inc. 915 8th Street, #201, Boone, IA. 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-24 Albert James Gotta jim@umtile.com Slater Boone IA Antonina M Gotta MARY KATE RUSSELL Signed (1) The corporation rejects the employers’ liability coverage. Albert James Gotta jim@umtile.com President Sole Share Holder Boone IA IA Antonina M Gotta Antonina M Gotta Signed
607 2023-02-20 21:53 Anonymous (not verified) 94.188.207.223 Rancheros construction LLC 1121 Linn Street Waterloo Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-15 Salvador Alvarez rancherosconstruction@outlook.com Waterloo Black hawk Iowa Adan Antonio Signed (1) The corporation rejects the employers’ liability coverage. Salvador Alvarez rancherosconstruction@outlook.com Owner Waterloo Black hawk Iowa Adan Antonio Signed
568 2022-11-15 08:23 Anonymous (not verified) 174.215.243.6 Cesar rolando Acosta rivera 2080 king ave apt 21 Des Moines ia 50320 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-15 Cesar rolando Acosta Rivera acostariveracesarrolando@gmail.com Des Moines Iowa Polk Iowa Juan acosta Antonio acosta Signed (1) The corporation rejects the employers’ liability coverage. Cesar rolando Acosta Rivera acostariveracesarrolando@gmail.com Owner Des moines Polk Iowa Juan acosta Antonio acosta Signed
569 2022-11-15 08:23 Anonymous (not verified) 174.215.243.6 Cesar rolando Acosta rivera 2080 king ave apt 21 Des Moines ia 50320 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-15 Cesar rolando Acosta Rivera acostariveracesarrolando@gmail.com Des Moines Iowa Polk Iowa Juan acosta Antonio acosta Signed (1) The corporation rejects the employers’ liability coverage. Cesar rolando Acosta Rivera acostariveracesarrolando@gmail.com Owner Des moines Polk Iowa Juan acosta Antonio acosta Signed
992 2024-05-17 09:04 Anonymous (not verified) 94.188.207.226 DEV Mart Inc 229 West St Grinnell IA I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-17 Rakesh Chaudhari grinnellmart@gmail.com Muscatine Muscatine Iowa Sam Chaudhari Arvind Chaudhari Signed (1) The corporation rejects the employers’ liability coverage. Rakesh Chaudhari grinnellmart@gmail.com Owner Muscatnine Iowa Iowa Sam Chaudhari Arvind Chaudhari Signed
560 2022-10-28 16:42 Anonymous (not verified) 207.177.1.151 CAC Tent LLC 2335 300th Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-10-28 Cory Allen Caldwell northiowatentandawning@gmail.com Ventura Hancock Iowa Chuck Forrest Ashley Kinnan Signed (1) The corporation rejects the employers’ liability coverage. Cory Caldwell northiowatentandawning@gmail.com Owner Ventura Hancock Iowa Chuck Forrest Ashley Kinnan Signed
210 2021-03-22 15:20 Anonymous (not verified) 204.155.61.217 Agspire Inc 1310 Kathryn Ct Buffalo, MN 55313 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-02-05 Kent Fiebelkorn kent@hailmayday.com Buffalo Wright County Minnesota DocuSign Ashley Kraft Signed (1) The corporation rejects the employers’ liability coverage. Kent Fiebelkorn kent@hailmayday.com Owner Buffalo Wright County Minnesota DocuSign Ashley Kraft Signed
211 2021-03-25 09:10 Anonymous (not verified) 204.155.61.217 The New Leaf Co 1095 Oakdale Ave, St Paul, MN 55118 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-02 Michael Hernandaz liveabovethecloudz@gmail.com St Paul Dakota MN DocuSign Ashley Kraft Signed (1) The corporation rejects the employers’ liability coverage. Michael Hernandaz liveabovethecloudz@gmail.com Ower St Paul Dakota mn DocuSign Ashley Kraft Signed
212 2021-03-25 09:26 Anonymous (not verified) 204.155.61.217 Mark Burger 3993 Shoreline Dr, Robbinsdale, MN 55422 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-03 Mark Burger markb@hailmayday.com Robbinsdale hennepin MN DocuSign Ashley Kraft Signed (1) The corporation rejects the employers’ liability coverage. Mark Burger markb@hailmayday.com Owner Robbinsdale Robbinsdale MN DocuSign Ashley Kraft Signed
348 2021-10-20 11:06 Anonymous (not verified) 97.116.100.220 Gonzalo construction LLC 5517 Brookdale Dr n apt 105 Brooklyn Park, mn 55443 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-10-20 Gonzalo Roman robles gonzaloconstructionmn@gmail.com Brooklyn park Hennepin Minnesora Gonzalo Roman robles Ashley Kraft Signed (1) The corporation rejects the employers’ liability coverage. Gonzalo Roman robles gonzaloconstruction@gmail.com Owner Brooklyn park Hennepin Minnesota Gonzalo Roman robles Ashley Kraft Signed
603 2023-02-16 16:11 Anonymous (not verified) 94.188.207.223 Transcend Mind Body Wellness and Floatation Clinic 409 Washington Street, Cedar Falls, IA 50613 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-01 Morgan Huls transcendcedarfalls@gmail.com Cedar Falls Black Hawk Iowa Brady Huls Ashlyn Henry Signed (1) The corporation rejects the employers’ liability coverage. Brady Huls transcendcfo@gmail.com CFO Cedar Falls Black Hawk Iowa Morgan Huls Ashlyn Henry Signed
604 2023-02-16 16:13 Anonymous (not verified) 94.188.207.226 Transcend Mind Body Wellness and Floatation Clinic 409 Washington Street, Cedar Falls, IA 50613 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-01 Brady Huls brady.huls@gmail.com Cedar Falls Black Hawk Iowa Morgan Huls Ashlyn Henry Signed (1) The corporation rejects the employers’ liability coverage. Morgan Huls transcendcedarfalls@gmail.com Owner Cedar Falls Black Hawk Iowa Brady Huls Ashlyn Henry Signed
525 2022-08-11 19:30 Anonymous (not verified) 216.51.251.59 Ethan pliner trucking 2510 Kansas ave fort dodge Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-08-11 Ethan William pliner pliner15@hotmail.com Fort dodge iowa Webster Iowa Trey Kent Lawrence Aubrey Mae Holtorf Signed (1) The corporation rejects the employers’ liability coverage. Ethan pliner pliner15@hotmail.com Owner Fort Dodge Webster Iowa Trey Kent Lawrence Aubrey Mae Holtorf Signed
213 2021-03-25 15:45 Anonymous (not verified) 173.20.159.129 Goldsmith Ventures, Inc. 308 E. Burlington St. #183 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-25 Jonathan Goldsmith jbg789@gmail.com Hills Johnson Iowa Monica Goldsmith Aura Rodriguez Signed (1) The corporation rejects the employers’ liability coverage. Jonathan Goldsmith jbg789@gmail.com Owner Hills Johnson Iowa Monica Goldsmith Aura Rodriguez Signed
537 2022-09-20 09:01 Anonymous (not verified) 173.20.206.50 Accent Painting LLC 613 Locust ST I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-20 Anthony Gilbert Gasco accentpainting@yahoo.com La Porte City Blackhawk Iowa Arthur Rudolf Gasco Aurora Jealee Gasco Signed (1) The corporation rejects the employers’ liability coverage. Anthony Gilbert Gasco accentpainting@yahoo.com Owner La Porte City Blackhawk Iowa Arthur Rudolf Gasco Aurora Jealee Gasco Signed
955 2024-04-11 10:31 Anonymous (not verified) 94.188.207.228 Calvillo & Son Construction 1802 mondamin ave Des Moines Iowa 50314 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-04-11 Gerardo Calvillo joedhsanchez@icloud.com Des Moines Polk Iowa Agustín Téllez Aurora Maciel Colin Signed (1) The corporation rejects the employers’ liability coverage. Gerardo Calvillo joedhsanchez@icloud.com Owner Des Moines Polk Iowa Agustín Téllez Aurora Maciel Colin Signed
957 2024-04-15 10:15 Anonymous (not verified) 94.188.207.226 Calvillo & Son Construction 1802 Mondamin Ave, Des Moines, Iowa, 50314 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2024-04-15 Gerardo Calvillo Joedhsanchez@icloud.com Des Moines Polk Iowa Agustín Téllez Aurora Maciel Colin Signed (2) The corporation declines to reject the employers’ liability coverage. Gerardo Calvillo Joedhsanchez@icloud.com Owner Des Moines Polk Iowa Agustín Téllez Aurora Maciel Colin Signed
566 2022-11-14 17:50 Anonymous (not verified) 107.77.206.66 JGR Carpentry 1305 N 6th St Apt. 11 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-14 Josiah Grant Robinson grantyboy87@yahoo.com Indianola Warren Iowa Timothy William Robinson Austin Micheal Ross Signed (1) The corporation rejects the employers’ liability coverage. Josiah Grant Robinson grantyboy87@yahoo.com Corporation President Indianola Warren Iowa Timothy William Robinson Austin Micheal Ross Signed
975 2024-05-06 14:30 Anonymous (not verified) 94.188.207.228 Plendl Farm Mangement LLC 4951 Harrison Ave, Maurice, IA 51036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-06 Christopher Plendl mcplendl@mtcnet.net Maurice Sioux IA Stacey Paulsen Austin Reitz Signed (1) The corporation rejects the employers’ liability coverage. Gerald Van Roekel gerald@veinsurance.com agent Orange City Sioux IA Stacey Paulsen Austin Reitz Signed
784 2023-10-09 13:09 Anonymous (not verified) 94.188.205.177 SEHIC G&S LLC 4201 62nd st apt 4 Urbandale Iowa 50322 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-09 Bajro Sehic kalesija20@gmail.com Urbandale Polk Iowa Bajro sehic Bajro sehic Signed (1) The corporation rejects the employers’ liability coverage. Bajro sehic kalesija20@gmail.com Owner Urbandale Polk Iowa Bajro sehic Bajro Sehic Signed
608 2023-02-22 16:15 Anonymous (not verified) 94.188.207.225 Unity Global Inc 1779 Shooting Star Ave, Fairfield, IA 52556 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-04 Hagen Rainbow unityglobalinc@protonmail.com Fairfield Jefferson Iowa Peter Defreitas Barbara Rainbow Signed (1) The corporation rejects the employers’ liability coverage. Hagen Rainbow unityglobalinc@protonmail.com President Fairfield Jefferson Iowa Peter Defreitas Barbara Rainbow Signed
40 2020-02-14 09:22 Anonymous (not verified) 50.83.38.221 Pa's Construction LLC 2350 Glass RD NE I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-02-14 Daniel Saunders dan2112411@yahoo.com Cedar Rapids USA_IA USA_IA Walt Cheney Becky Cheney Signed (1) The corporation rejects the employers’ liability coverage. Daniel Saunders dan2112411@yahoo.com Owner- Manager Cedar Rapids USA_IA USA_IA Walt Cheney Becky Cheney Signed
708 2023-07-14 09:24 Anonymous (not verified) 94.188.205.166 Ellis Flying Service Inc. 6550 HWY 17 South Newport AR 72112 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-14 Mark Ellis fly@ellisflying.com Newport Arkansas United States Alex Webb Becky Ellis Signed (1) The corporation rejects the employers’ liability coverage. Mark A Ellis fly@ellisflying.com President Newport Arkansas United States Alex Webb Becky Ellis Signed
431 2022-03-25 15:47 Anonymous (not verified) 199.241.229.222 Ney Trucking Inc 5070 Wolff Rd Dubuque, IA 52002 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-25 Maria A Ney maria@neytrucking.com Peosta Dubuque IA Brenda Weatherwax Becky Schmelzer Signed (1) The corporation rejects the employers’ liability coverage. Maria Ney maria@neytrucking.com President Peosta Dubuque IA Brenda Weatherwax Becky Schmelzer Signed
432 2022-03-25 15:49 Anonymous (not verified) 199.241.229.222 Ney Trucking Inc 5070 Wolff Rd Dubuque, IA 52002 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-25 Marvin L Ney marvin@paramountems.com Peosta Dubuque IA Brenda Weatherwax Becky Schmelzer Signed (1) The corporation rejects the employers’ liability coverage. Maria Ney maria@neytrucking.com President Peosta Dubuque IA Brenda Weatherwax Becky Schmelzer Signed
903 2024-02-27 13:54 Anonymous (not verified) 94.188.205.166 MELTZ'S CONSTRUCTION LLC 402 Jennifer Ln NE Cedar Rapids IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-27 RICARDO MELTZ waymakeranasolorzano@gmail.com CADAR RAPIDS IA United States Lysandra Betancourt Belkis S Diaz Signed (1) The corporation rejects the employers’ liability coverage. ALAN SALGADO alan@prime-agents.com OWNER IRVING TX United States Lysandra Betancourt Belkis S Diaz Signed
45 2020-03-10 10:24 Anonymous (not verified) 204.141.214.180 Shamrock Screenprinting Inc 2710 Granite Ct NE I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-03-10 Lori Handley lori.handley@aol.com Cedar Rapids Linn IA David Handley Beth Barta Signed (1) The corporation rejects the employers’ liability coverage. Lori Handley lori.handley@aol.com VP Cedar Rapids Linn IA David Handley Beth Barta Signed
46 2020-03-10 10:26 Anonymous (not verified) 204.141.214.180 Shamrock Screenprinting Inc 2710 Granite Ct NE I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-03-10 David Handley davehandley53@gmail.com Cedar Rapids Linn IA Lori Handley Beth Barta Signed (1) The corporation rejects the employers’ liability coverage. Lori Handley Lori.handley@aol.com VP Cedar Rapids Linn IA Lori Handley Beth Barta Signed
373 2021-12-10 14:49 Anonymous (not verified) 173.29.69.100 CARSTENS FLOOR COVERINGS LLC 19276 250TH STREET ELDRIDGE, IA 52748 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-12-10 MATHEW CARSTENS MCARSTENS@NETINS.NET ELDRIDGE SCOTT IA TONY BURKHART BETH LEMONS Signed (1) The corporation rejects the employers’ liability coverage. MATTHEW CARSTENS MCARSTENS@NETINS.NET PRESIDENT ELDRIDGE SCOTT IA TONY BURKHART BETH LEMONS Signed
16 2019-12-12 13:17 Anonymous (not verified) 65.126.161.162 MGF Concrete DBA Michael Frandsen 3306 66th Avenue Moline, IL 61265 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2019-12-12 Michael Frandsen None@none.com Moline Rock Island Illinois Sarah Robertson Beth Welzenbach Signed (1) The corporation rejects the employers’ liability coverage. Michael Frandsen None@none.com Owner Moline Rock Ilsand Illinois Sarah Robertson Beth Welzenbach Signed
17 2019-12-12 13:20 Anonymous (not verified) 65.126.161.162 Robert J Schroeder Const. Inc. 10984 150th St Davenport, IA 52804 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2019-12-12 Robert J Schroeder None@none.com Davenport Scott Iowa Sarah Robertson Beth Welzenbach Signed (1) The corporation rejects the employers’ liability coverage. Robert J Schroeder None@none.com President Davenport Scott Iowa Sarah Robertson Beth Welzenbach Signed
23 2019-12-31 09:01 Anonymous (not verified) 65.126.161.162 Shawn Watson DBA SW Painting 1205 13th Ave Orion, IL 61273 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2019-12-31 Shawn Michael Watson None@none.com Orion Henry Illinois Sarah Robertson Beth Welzenbach Signed (1) The corporation rejects the employers’ liability coverage. Shawn Watson None@none.com Owner Orion Henry Illinois Sarah Robertson Beth Welzenbach Signed
47 2020-03-10 15:16 Anonymous (not verified) 65.126.161.162 Advantage Customer Remodeling LLC 3236 W 17th Street Davenport, IA 52804 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-03-10 Tamethia Mitchell None@none.com Davenport Scott Iowa Sarah Robertson Beth Welzenbach Signed (1) The corporation rejects the employers’ liability coverage. Tamethia Mitchell None@none.com Owner Davenport Scott Iowa Sarah Robertson Beth Welzenbach Signed
59 2020-04-14 12:54 Anonymous (not verified) 65.126.161.162 Elite Carpentry 1515 21st Street Bettendorf, IA 52722 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-10 Jeffrey D. Leech elitecarpentryqc@gmail.com Bettendorf Scott Iowa Sarah Robertson Beth Welzenbach Signed (2) The corporation declines to reject the employers’ liability coverage. Jeffrey D. Leech elitecarpentryqc@gmail.com President Bettendorf Scott Iowa Sarah Robertson Beth Welzenbach Signed
69 2020-04-21 10:18 Anonymous (not verified) 65.126.161.162 Mike Foster DBA Mike's Home Improvement 2377 W 49th Street Davenport, IA 52806 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-21 Michael A Foster Jr. None@none.com Davenport Scott Iowa Sarah Robertson Beth Welzenbach Signed (1) The corporation rejects the employers’ liability coverage. Michael A Foster Jr. None@none.com Owner Davenport Scott Iowa Sarah Robertson Beth Welzenbach Signed
890 2024-02-19 12:07 Anonymous (not verified) 94.188.205.174 FJ Orisa Construction Inc 114 Austin Street SW I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-19 Jennifer LynnWeirup FJOrisaconstruction@yahoo.com Cedar Rapids Linn IA Karen Sedlacek Billie Jo Moore Signed (1) The corporation rejects the employers’ liability coverage. jennifer lynn weirup FJOrisaconstruction@yahoo.com self Cedar Rapids Iowa Iowa Karen Sedlacek Billie Jo Moore Signed
891 2024-02-19 12:09 Anonymous (not verified) 94.188.205.169 FJ Orisa Construction Inc 114 Austin Street SW I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-19 Felipe Aldana FJOrisaconstruction@yahoo.com Cedar Rapids Linn IA Karen Sedlacek Billie Jo Moore Signed (1) The corporation rejects the employers’ liability coverage. Felipe Aldana FJOrisaconstruction@yahoo.com officer Cedar Rapids Iowa Iowa Karen Sedlacek Billie Jo Moore Signed
318 2021-08-23 11:00 Anonymous (not verified) 216.51.164.69 Z Homes and Realty Inc 1324 3rd Ave SE Sioux Center IA 51250 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-05-19 Beverly Zwart mbzwrt@mtcnet.net Sioux Center Sioux IA Lisa Dykstra Blake Kruger Signed (1) The corporation rejects the employers’ liability coverage. Beverly Zwart mbzwrt@mtcnet.net Owner Sioux Center Sioux IA Lisa Dykstra Blake Kruger Signed
390 2022-01-20 11:06 Anonymous (not verified) 162.246.237.102 High Pointe Construction 903 Summerset pl Indianola iowa 50125 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-19 Andrey Shabak shabakandre@gmail.com indianola warren Iowa Inna zayets bob Signed (1) The corporation rejects the employers’ liability coverage. Andrey shabak shabakandre@gmail.com owner indianola warren ia inna zayets bob Signed
94 2020-07-02 08:19 Anonymous (not verified) 174.217.21.87 James Subcontracting 5212 South Union st. I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-07-02 James Lee Wardell jlw21479@gmail.com Des Moines IA United States Tammy Wardell Bobby Hoch Signed (1) The corporation rejects the employers’ liability coverage. James Subcontracting jlw21479@gmail.com Owner Des Moines IA United States Tammy Wardell Bobby Hoch Signed
379 2022-01-04 14:10 Anonymous (not verified) 97.107.199.129 Premier Show Productions 1304 Skyline Dr Council Bluffs IA I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-20 Scott Brandenburg scottsuperiorservices@gmail.com Council Bluffs POtt Iowa Jan andersen Brad Andersen Signed (1) The corporation rejects the employers’ liability coverage. Scott Brandenburg scottsuperiorservices@gmail.com self Council Bluffs Pott Iowa Jan Andersen Brad Andersen Signed
561 2022-11-03 11:24 Anonymous (not verified) 96.31.21.117 Northwest 9 Inc. 1512 Elmwood Ave. I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-03 Ethan Meyer ethanmeyer83@gmail.com ROCK RAPIDS Iowa United States Brad Meyer Trinda Meyer Signed (1) The corporation rejects the employers’ liability coverage. Brad Meyer nw9farm@gmail.com owner Rock Rapids IA United States Trinda Meyer Brad Meyer Signed
209 2021-03-19 11:44 Anonymous (not verified) 206.80.128.67 GSW Farms INC 25277 HWY K45 Onawa, IA 51040 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-19 Gregory Willey sgwilley@gmail.com Onawa Monona Iowa Jacob Willey Brad Rock Signed (1) The corporation rejects the employers’ liability coverage. Gregory Willey sgwilley@gmail.com President Onawa Monona Iowa Jacob Willey Brad Rock Signed
521 2022-07-25 15:33 Anonymous (not verified) 199.66.14.149 ROSENBERGER ENTERPRISES, INC. 1813 N 7th St INDIANOLA, IA 50125 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-25 Diane Rosenberger diane@katanainc.com Indianola IA United States SPRING CRUBAUGH BRADY FRY Signed (2) The corporation declines to reject the employers’ liability coverage. Diane Rosenberger diane@katanainc.com Owner Indianola IA United States SPRING CRUBAUGH BRADY FRY Signed
606 2023-02-20 20:55 Anonymous (not verified) 94.188.205.168 Carlos Ortiz LLC 4335 NE 23rd Ave Des Moines, IA 50317 Estados Unidos I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-02-20 Carlos Ortiz carlosoframing@gmail.com Des Moines Polk Iowa Luz picazo Brando ortiz Signed (1) The corporation rejects the employers’ liability coverage. Carlos Ortiz carlosograming@gmail.com Owner Des Moines Polk Iowa Luz picazo Brando Ortiz Signed
810 2023-11-09 17:41 Anonymous (not verified) 94.188.205.167 Chad Ripple's Painting LLC 899 NW 45th Ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-09 Chad Ripple ia515@hotmail.com Des Moines Polk Iowa Ron Spurgeon Brandon Haus Signed (1) The corporation rejects the employers’ liability coverage. Chad Ripple ia515@hotmail.com President Des Moines Polk Iowa Ron Spurgeon Brandon Haus Signed
809 2023-11-08 09:47 Anonymous (not verified) 94.188.207.229 GruntWorkz Wedling and Fab, Inc. 15519 80th Ave Blue Grass, IA 52726 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-08 Brandon Joseph Fox GruntWorkzwelding@gmail.com Blue Grass Scott Iowa Amanda Dawn Fox Brandon Joseph Fox Signed (1) The corporation rejects the employers’ liability coverage. Brandon Joseph Fox GruntWorkzwelding@gmail.com Same Person Blue Grass Scott Iowa Amanda Dawn Fox Brandon Joseph Fox Signed
423 2022-03-08 12:17 Anonymous (not verified) 173.18.193.171 BARNES INC 1214 40TH ST FORT MADISON IA 52627 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-08 dwight barnes humburdautoservice455@gmail.com Fort Madison Iowa United States Tyson P Barnes Brandon L Barnes Signed (1) The corporation rejects the employers’ liability coverage. dwight barnes humburdautoservice455@gmail.com President Fort Madison Iowa United States Tyson P Barnes Brandon L Barnes Signed
433 2022-03-27 15:30 Anonymous (not verified) 208.126.206.146 J B Engraving 206 4th street East Newhall , Iowa 52315 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-27 John Lauterwasser engravingjb@gmail.com Newhall Benton Iowa Lisa Jane Meeks Brandon Lauterwasser Signed (1) The corporation rejects the employers’ liability coverage. LC Anderson lbandins@southslope.net N/A Newhall Benton Iowa Lisa Jane Meeks Brandon Lauterwasser Signed
434 2022-03-27 15:30 Anonymous (not verified) 208.126.206.146 J B Engraving 206 4th street East Newhall , Iowa 52315 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-27 John Lauterwasser engravingjb@gmail.com Newhall Benton Iowa Lisa Jane Meeks Brandon Lauterwasser Signed (1) The corporation rejects the employers’ liability coverage. LC Anderson lbandins@southslope.net N/A Newhall Benton Iowa Lisa Jane Meeks Brandon Lauterwasser Signed
51 2020-03-30 11:01 Anonymous (not verified) 45.42.5.219 Iowa Roofpros 104 Anderson Street, Maquoketa, IA 52060 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-03-17 Heather Nienke heather@nienkesolar.com Maquoketa Jackson Iowa Derrick Parsons Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. Heather Nienke heather@nienkesolar.com Co-owners Maquoketa Jackson Iowa Derrick Parsons Brenda Lewis Signed
52 2020-03-30 11:04 Anonymous (not verified) 45.42.5.219 Iowa Roofpros 104 Anderson Street, Maquoketa, IA 52060 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-03-17 Jamison Nienke iowaroofguru@gmail.com Maquoketa Jackson Iowa Derrick Parsons Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. Jamison Nienke iowaroofguru@gmail.com Co-owners Maquoketa Jackson Iowa Derrick Parsons Brenda Lewis Signed
167 2021-01-26 11:56 Anonymous (not verified) 74.84.91.178 Shea Real Estate LLC 135 Devon Drive, Dubuque, IA 52001 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-17 Lucas Kahl shearealestatellc@gmail.com Dubuque Dubuque Iowa Gabe Drewelow Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. Lucas Kahl shearealestatellc@gmail.com President Dubuque Dubuque Iowa Gabe Drewelow Brenda Lewis Signed
168 2021-01-26 12:06 Anonymous (not verified) 74.84.91.178 RAM Services 13276 Harvest Mood Ridge, Sherrill, IA 52073 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-11 Dusty Herbst dustyherbst@hotmail.com Sherrill Dubuque Iowa Derrick Parsons Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. Dusty Herbst dustyherbst@hotmail.com President Sherrill Dubuque Iowa Derrick Parsons Brenda Lewis Signed
169 2021-01-26 12:20 Anonymous (not verified) 74.84.91.178 Sunset Ridge Winery LLC 12615 Highway 52 North, Dubuque, IA 52002 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-07 John Bonnette jbonnette@yahoo.com Dubuque Dubuque Iowa Derrick Parsons Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. John Bonnette jbonnette@yahoo.com Officer Dubuque Dubuque Iowa Derrick Parsons Brenda Lewis Signed
170 2021-01-26 12:23 Anonymous (not verified) 74.84.91.178 Sunset Ridge Winery LLC 12615 Highway 52 North, Dubuque, IA 52002 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-07 Ann Bonnette jbonnette@yahoo.com Dubuque Dubuque Iowa Derrick Parsons Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. Ann Bonnette jbonnette@yahoo.com Officer Dubuque Dubuque Iowa Derrick Parsons Brenda Lewis Signed
232 2021-04-12 11:14 Anonymous (not verified) 74.84.91.178 Heim Enterprises LLC 13532 Mueller Parkway, Sherrill, IA 52073 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-01 Cory Heim corypheim@gmail.com Sherrill Dubuque Iowa Gabe Drewelow Brenda Lewis Signed (2) The corporation declines to reject the employers’ liability coverage. Cory Heim corypheim@gmail.com owner Sherrill Dubuque Iowa Gabe Drewelow Brenda Lewis Signed
110 2020-08-25 14:31 Anonymous (not verified) 199.241.229.222 Ney Trucking Inc 5070 Wolff Rd Dubuque, IA 52002 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-08-25 Marvin L Ney marvin@paramountems.com Peosta Dubuque Iowa Karen Ludovissy Brenda Weatherwax Signed (1) The corporation rejects the employers’ liability coverage. Maria A Ney maria@paramountems.com Secretary Peosta Dubuque IA Karen Ludovissy Brenda Weatherwax Signed
833 2023-12-12 07:31 Anonymous (not verified) 94.188.207.224 Axe-cade LLC 136 E Main Street Anamosa, IA 52205 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-12 Teresa Coons axecadeonmain@gmail.com Anamosa Iowa United States Chad Coons Bret Funke Signed (1) The corporation rejects the employers’ liability coverage. Chad Coons ccoons03@gmail.com Member Anamosa Iowa United States Teresa Coons Bret Funke Signed
229 2021-04-05 13:44 Anonymous (not verified) 173.18.193.51 Denmark Sanitary District PO Box 141, Denmark, Iowa 52624 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-03 Clay Fullenkamp judy@fullenkampins.com West Point Lee Iowa Judy Moeller Brian Stuekerjuergen Signed (2) The corporation declines to reject the employers’ liability coverage. Clay Fullenkamp judy@fullenkampins.com Board Member West Point Lee Iowa judy moeller brian stuekerjuergen Signed
871 2024-01-26 09:16 Anonymous (not verified) 94.188.205.168 NeX Level Restoration 314 8th St NW, Cedar Rapids, IA, 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-26 Trevor McCauley jhawktm@gmail.com Cedar Rapids Linn Iowa Bridget Camp Bridget Camp Signed (1) The corporation rejects the employers’ liability coverage. Trevor McCauley jhawktm@gmail.com Self Cedar Rapids Linn Iowa Bridget Camp Bridget Camp Signed
117 2020-09-11 11:54 Anonymous (not verified) 162.218.1.22 american business resource corporation 4600 American Parkway Suite #301 Madison, WI 53718 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-11 Michelle Szabrowicz mszabrowicz@abrjobs.com Madison Dane Wisconsin Patricia Haggerty Britney Mollet Signed (1) The corporation rejects the employers’ liability coverage. Michelle Szabrowicz mszabrowicz@abrjobs.com CFO Madison Dane Wisconsin Patricia Haggerty Britney Mollet Signed
924 2024-03-19 16:40 Anonymous (not verified) 94.188.207.228 Brite-Way Services Inc. 621 Morningside Dr., Burlington IA 52601 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-19 Richard Luckenbill britewayburl@gmail.com Burlington Iowa Iowa Tammy Luckenbill Brooke Mathiasmeier Signed (1) The corporation rejects the employers’ liability coverage. Richard Luckenbill britewayburl@gmail.com Owner, President Burlington Iowa Iowa Tammy Luckenbill Brooke Mathiasmeier Signed
765 2023-09-12 12:44 Anonymous (not verified) 94.188.207.229 Southwest Sanitation Inc Clarinda, Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-09-12 Lindsay A Schrock swsanitation@gmail.com Bedford Taylor Iowa Robin Wilmarth Bryan Wilmarth Signed (1) The corporation rejects the employers’ liability coverage. Lindsay Schrock swsanitation@gmail.com Treasure Bedford Taylor Iowa Robin Wilmarth Bryan Wilmarth Signed
766 2023-09-12 12:46 Anonymous (not verified) 94.188.207.224 Southwest Sanitation Clarinda, Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-09-12 Craig Schrock swsanitation@gmail.com Bedford Taylor Iowa Robin Wilmarth Bryan Wilmarth Signed (1) The corporation rejects the employers’ liability coverage. Lindsay Schrock swsanitation@gmail.com Treasure Bedford Taylor Iowa Robin Wilmarth Bryan Wilmarth Signed
767 2023-09-12 12:48 Anonymous (not verified) 94.188.207.223 Southwest Sanitation Clarinda, Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-09-12 Lonnie Weed swsanitation@gmail.com Bedford Taylor Iowa Robin Wilmarth Bryan Wilmarth Signed (1) The corporation rejects the employers’ liability coverage. Lindsay Schrock swsanitation@gmail.com Treasure Bedford Taylor Iowa Robin Wilmarth Bryan Wilmarth Signed
769 2023-09-12 12:49 Anonymous (not verified) 94.188.207.223 Southwest Sanitation Clarinda, Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-09-12 Joshua Weed swsanitation@gmail.com Bedford Taylor Iowa Robin Wilmarth Bryan Wilmarth Signed (1) The corporation rejects the employers’ liability coverage. Lindsay Schrock swsanitation@gmail.com Treasure Bedford Taylor Iowa Robin Wilmarth Bryan Wilmarth Signed
926 2024-03-20 15:25 Anonymous (not verified) 94.188.207.230 CML Constuction LLC 2116 Park Ave Muscatine, Iowa 52761 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-20 CHRIS LINNENKAMP cmlconstructionllc@gmail.com Muscatine IA IA Gabriel Diaz Byron Lopez Signed (1) The corporation rejects the employers’ liability coverage. CHRIS LINNENKAMP cmlconstructionllc@gmail.com Owner Muscatine IA IA Gabriel Diaz Byron Lopez Signed
226 2021-04-01 11:52 Anonymous (not verified) 97.125.87.4 JK Holdings 1300 NW 100TH ST. Suite 3000 Clive, IA 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 Joey Boyens ekindesmoines@gmail.com Clive Polk Iowa Jenae Halstead Cam Naylor Signed (1) The corporation rejects the employers’ liability coverage. Jenae Halstead ekindesmoines@gmail.com Manager Clive Polk Iowa Joey Boyens Cam Naylor Signed
801 2023-10-25 08:32 Anonymous (not verified) 94.188.205.177 CEM Businesses LLC 608 Evergreen Cir NW Bondurant, IA 50035 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-10-25 Dane McDonald danemcdonald2@gmail.com Bondurant Polk Iowa Raelynn Aicher Cameron VanBuren Signed (1) The corporation rejects the employers’ liability coverage. Dane McDonald dane.mcdonald@stellar-solar.net Self Bondurant Polk Iowa Raelynn Aicher Cameron VanBuren Signed
803 2023-10-25 08:37 Anonymous (not verified) 94.188.205.166 CEM Businesses LLC 608 Evergreen Cir NW Bondurant, IA 50035 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-25 Ryan Canales ryancanales44@gmail.com West Des Moines Polk Iowa Raelynn Aicher Cameron VanBuren Signed (2) The corporation declines to reject the employers’ liability coverage. Dane McDonald dane.mcdonald@stellar-solar.net Self Bondurant Polk Iowa Raelynn Aicher Cameron VanBuren Signed
848 2024-01-05 13:05 Anonymous (not verified) 94.188.205.177 NeX Level Moving, LLC 5634 Deerwood St. SW, Cedar Rapids, IA, 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-05 William J Feldmann feldmannwng@msn.com Anamosa Jones Iowa Bridget Camp Signed (1) The corporation rejects the employers’ liability coverage. William J Feldmann feldmannwng@msn.com Self Anamosa Jones Iowa Bridget Camp Signed
621 2023-03-08 07:53 Anonymous (not verified) 94.188.207.223 Don Wyckoff Heating Inc. 95 Highway 5, Carlisle, IA 50047 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-04 Michael T Johnson mikeyjay1968@gmail.com Des Moines Polk IA Brady Cooper Carey Cooper Signed (1) The corporation rejects the employers’ liability coverage. Mike Johnson mikeyjay@gmail.com Sub-Contractor Des Moines Polk IA Brady Cooper Carey Cooper Signed
127 2020-10-28 14:42 Anonymous (not verified) 104.207.31.201 Little Bison Childcar Center, Inc. 404 2nd St NW I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-10-28 Travis Brass travis.brass@rakestatesavingsbank.com Lakota Kossuth Iowa Tami Jacobson Carol Winter Signed (1) The corporation rejects the employers’ liability coverage. Travis Brass travis.brass@rakestatesavingsbank.com Treasurer Lakota Kossuth Iowa Tami Jacobson Carol Winter Signed
661 2023-04-29 10:04 Anonymous (not verified) 94.188.205.177 Planetary Tree Service 166 Brovan blvd, evansdale, iowa 50707 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-04-29 Andrew Jon Collins thetreeguy2000@gmail.com Evansdale Black Hawk Iowa Jennifer Selleck Carolyn Inman Signed (1) The corporation rejects the employers’ liability coverage. Andrew Jon Collins thetreeguy2000@gmail.com Owner Evansdale Black hawk Iowa Jennifer renee selleck Carolyn kay Inman Signed
714 2023-07-25 16:16 Anonymous (not verified) 94.188.207.224 Midwest Systems 2877 130th St Aurora, Ia 50607 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-25 Matt Griswold midwestsystems@live.com Aurora IA United States Creatleigh Griswold Carslyn Griswold Signed (1) The corporation rejects the employers’ liability coverage. Matt Griswold midwestsystems@live.com Owner Aurora IA United States Creatleigh Griswold Carslyn Griswold Signed
747 2023-08-19 15:30 Anonymous (not verified) 94.188.207.229 Arneson Tree Service 901 s Washington st Lake Mills IOWA 50450 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-19 Charles Douglas Arneson charles.arneson@aol.com Lake Mills Winnebago IOWA Amber Arneson Carter Arneson Signed (1) The corporation rejects the employers’ liability coverage. Charles Douglas Arneson charles.arneson@aol.com Owner Lake Mills Winnebago IOWA Amber arneson Carter Arneson Signed
596 2023-02-06 08:08 Anonymous (not verified) 107.121.104.18 Household Nanny 1357 Woolridge Dr., Coralville, IA 52241 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-02-06 Stephen John Statz sstatz32@gmail.com Coralville IA United States Jeffrey Peterson Casey Edwards Signed (1) The corporation rejects the employers’ liability coverage. Stephen John Statz sstatz32@gmail.com Owner Coralville IA United States Jeffrey Peterson Casey Edwards Signed
597 2023-02-06 08:11 Anonymous (not verified) 107.121.104.18 Household Nanny 1357 Woolridge Dr., Coralville, IA 52241 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-02-06 Giselle Marie Statz Gisellestatz@gmail.com Coralville IA United States Jeffrey Peterson Casey Edwards Signed (1) The corporation rejects the employers’ liability coverage. Giselle Marie Statz gisellestatz@gmail.com Owner CORALVILLE Johnson Iowa Jeffrey Peterson Casey Edwards Signed
583 2022-12-09 11:29 Anonymous (not verified) 74.84.79.78 Captain Kirk Construction 202 W Guthrie St. Linden, IA 50146 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-01 William Kirj iicaptainkirk@gmail.com Linden Dalas Iowa Michael O'Conner Ron Rand Signed (1) The corporation rejects the employers’ liability coverage. William Kirk iicaptainkirk@gmail.com Owner Linden Dallas IA Michael O'Conner Casey Kirk Signed
304 2021-08-07 03:43 Anonymous (not verified) 50.81.215.27 VALLE SERVICES LLC 6520 N DIVISION ST I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-07 LAURA VALLE iavalleservicesllc@gmail.com DAVENPORT IA United States bryon hakes celia valle Signed (1) The corporation rejects the employers’ liability coverage. LAURA VALLE iavalleservicesllc@gmail.com owner DAVENPORT IA United States bryon hakes celia valle Signed
444 2022-04-14 15:50 Anonymous (not verified) 72.10.21.42 Babcock Services Idaho, Inc. 8113 W QUINAULT AVENUE 201, Kennewick, WA 99336 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-14 Carmen Clyde CCLYDE@BABCOCKSERVICES.COM KENNEWICK WA Washington Linda McAlister Cesar Jimenez Signed (1) The corporation rejects the employers’ liability coverage. CARMEN CLYDE CCLYDE@BABCOCKSERVICES.COM Secretary KENNEWICK Benton Washington Linda McAlister Cesar Jimenez Signed
445 2022-04-14 15:52 Anonymous (not verified) 72.10.21.42 Babcock Services Idaho, Inc. 8113 W QUINAULT AVENUE 201, Kennewick, WA 99336 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-14 Keith Myers CCLYDE@BABCOCKSERVICES.COM KENNEWICK Benton Washington Linda McAlister Cesar Jimenez Signed (1) The corporation rejects the employers’ liability coverage. CARMEN CLYDE CCLYDE@BABCOCKSERVICES.COM Secretary KENNEWICK Benton Washington Linda McAlister Cesar Jimenez Signed
446 2022-04-14 15:54 Anonymous (not verified) 72.10.21.42 Babcock Services Idaho, Inc. 8113 W QUINAULT AVENUE 201, Kennewick, WA 99336 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-14 Phil Gallagher pgallagher@babcockservices.com Richland Benton Washington Linda McAlister Cesar Jimenez Signed (1) The corporation rejects the employers’ liability coverage. CARMEN CLYDE CCLYDE@BABCOCKSERVICES.COM Secretary KENNEWICK Benton Washington Linda McAlister Cesar Jimenez Signed
721 2023-08-01 09:24 Anonymous (not verified) 94.188.205.167 Dryseal Roofing and Construction 390 Olive St Martensdale, IA 50160 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-01 Travis Tibbits travistibbits@yahoo.com Martensdale Warren IA Hannah Marie Tibbits Chad David Walker Signed (1) The corporation rejects the employers’ liability coverage. Dawn Marie Tibbits Tibbits6@gmail.com Spouse Martensdale Warren IA Hannah Marie Tibbits Chad David Walker Signed
439 2022-03-29 19:23 Anonymous (not verified) 173.215.72.139 Vinton Enterprises LLC 24704 Isbell Lane, Glenwood, IA 51534 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-29 Holly Vinton vintonfive@hotmail.com Glenwood Mills Iowa David Pratt Chad MIller Signed (1) The corporation rejects the employers’ liability coverage. Holly Vinton vintonfive@hotmail.com owner Glenwood Mills Iowa David Pratt Chad Miller Signed
553 2022-10-03 15:32 Anonymous (not verified) 165.206.254.105 Ski Mechanical Services 729 Bell Ave. Des Moines, IA 50315 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-10-03 Terry Wave Konchalski skiwave79@gmail.com Des Moines Polk Iowa Melissa Kerr Charlie Ruperto Signed (1) The corporation rejects the employers’ liability coverage. Terry Wave Konchalski skiwave79@gmail.com Owner/President Des Moines Polk Iowa Melissa Kerr Charlie Ruperto Signed
490 2022-06-03 10:14 Anonymous (not verified) 70.96.153.153 Reicks Construction Inc 5415 Alburnett Rd, Marion, IA 52302 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-03 Victor Reicks victor@optionsexteriors.com Marion Linn County Iowa Austin Miller Charlotte Rasmussen Signed (1) The corporation rejects the employers’ liability coverage. Victor Reicks victor@optionsexteriors.com Owner Marion Linn County Iowa Austin Miller Charlotte Rasmussen Signed
705 2023-07-06 14:24 Anonymous (not verified) 94.188.205.167 Portwood H3D Consulting 1109 295th Street, Oxford Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-06 Brian Portwood portwoodh3dconsulting@gmail.com Oxford Johnson Iowa Bob Herring Chelsey Atkinson Signed (1) The corporation rejects the employers’ liability coverage. Brian Portwood portwoodh3dconsulting@gmail.com owner Oxford Johnson Iowa Bob Herring Chelsey Atkinson Signed
399 2022-02-03 09:03 Anonymous (not verified) 207.199.230.75 Heart of Iowa Inspections LLC 2700 Highway 63 Oskaloosa Iowa 52577 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-03 Randy DeHeer rdeheer2828@gmail.com Oskaloosa Mahaska Iowa Doris Crile Cheryl Brown Signed (1) The corporation rejects the employers’ liability coverage. Randy DeHeer rdeheer2828@gmail.com self Oskaloosa Mahaska Iowa Doris Crile Cheryl Brown Signed
55 2020-04-06 16:25 Anonymous (not verified) 74.221.44.37 Steele Land & Livestock, Inc 1040 190th St, Anita, IA 50020 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-06 Doug Steele dsteele@midlands.net Anita Adair Iowa Sheryl Leonard Cheryl Ellis Signed (1) The corporation rejects the employers’ liability coverage. Doug Steele dsteele@midlands.net President Anita Adair Iowa Sheryl Leonard Cheryl Ellis Signed
332 2021-09-13 13:30 Anonymous (not verified) 173.23.250.91 Cheri’s roofing 230 palomino pkwy Des Moines Iowa 50320 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2021-09-13 Cheryl Martinez cheri6876@yahoo.com Des Moines Polk Iowa Cheryl Martinez Cheryl martinez Signed (1) The corporation rejects the employers’ liability coverage. Chery Martinez cheri6876@yahoo.com Owner Des Moines Polk Iowa Cheryl Martinez Cheryl Martinez Signed
847 2024-01-04 21:10 Anonymous (not verified) 94.188.207.227 C & L Construction 721 NE 60th St, Pleasant Hill, IA 50327 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-04 Jose M Sanchez Melendez landerosmary@gmail.com Pleasant Hill Polk Iowa Marianna Landeros Cheryl Martinez Signed (1) The corporation rejects the employers’ liability coverage. Jose M Sanchez Melendez landerosmary@gmail.com Self Pleasant Hill Polk Iowa Marianna Landeros Cheryl Martinez Signed
678 2023-06-06 10:28 Anonymous (not verified) 94.188.205.177 William Terrance Harshbarger Jr. 27225 115th Avenue, Donahue IA 52746 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-06 William Terrance Harshbarger Jr. harzyhd1@hotmail.com Donahue Scott Iowa Margaret Tucker Cheryl Piersall Signed (1) The corporation rejects the employers’ liability coverage. William Terrance Harshbarger Jr. harzyhd1@hotmail.com self Donahue Scott Iowa Margaret Tucker Cheryl Piersall Signed
679 2023-06-06 10:36 Anonymous (not verified) 94.188.205.174 William Terrance Harshbarger Jr. 27225 115th Avenue, Donahue IA 52746 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-06 William Terrance Harshbarger Jr. harzyhd1@hotmail.com Donahue Scott Iowa Margaret Tucker Cheryl Piersall Signed (1) The corporation rejects the employers’ liability coverage. William Terrance Harshbarger Jr. harzyhd1@hotmail.com self Donahue Scott Iowa Margaret Tucker Cheryl Piersall Signed
428 2022-03-23 12:00 Anonymous (not verified) 76.76.231.229 Connelly Sanitation Inc 108 S. 14th St. Fairfield IA 52556 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-23 Richard Raymond Vogt connelly.inc@outlook.com Fairfield Jefferson Iowa Mindy Lynn Vogt Chester James Vogt Signed (1) The corporation rejects the employers’ liability coverage. Richard Raymond Vogt connelly.inc@outlook.com Self Fairfield Jefferson Iowa Mindy Lynn Vogt Chester James Vogt Signed
623 2023-03-08 13:48 Anonymous (not verified) 94.188.205.174 Jim & Laini's Trucking Inc 11591 Rupp Hollow Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-08 James Harry jltiowa@gmail.com DUBUQUE IA United States Christopher T Clarke Chris Clarke Signed (1) The corporation rejects the employers’ liability coverage. James Harry jltiowa@gmail.com owner DUBUQUE IA United States Christopher T Clarke Chris Clarke Signed
624 2023-03-08 13:50 Anonymous (not verified) 94.188.205.177 Jim & Laini's Trucking Inc 11591 Rupp Hollow Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-08 Elaine Harry jltiowa@gmail.com DUBUQUE Iowa United States Christopher T Clarke Chris Clarke Signed (1) The corporation rejects the employers’ liability coverage. James Harry jltiowa@gmail.com owner DUBUQUE IA United States Christopher T Clarke Chris Clarke Signed
952 2024-04-08 17:25 Anonymous (not verified) 94.188.205.175 Bio-Inspired Design Aeronautics Corp 6843 Still Creek Pass I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-08 Joseph Mitchell aerotech@hush.com Bettendorf Iowa United States Mike Owens Chris DeCock Signed (1) The corporation rejects the employers’ liability coverage. Hollie Mitchell mitchhollie@yahoo.com Vice President Bettendorf Iowa United States Mike Owens Chris DeCock Signed
953 2024-04-08 17:35 Anonymous (not verified) 94.188.205.174 Bio-Inspired Design Aeronautics Corp 6843 Still Creek Pass I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-08 Hollie Mitchell mitchhollie@yahoo.com Bettendorf Iowa United States Mike Owens Chris DeCock Signed (1) The corporation rejects the employers’ liability coverage. Joseph Mitchell aerotech@hush.com President Bettendorf Iowa United States Mike Minnich Chris DeCock Signed
954 2024-04-08 17:38 Anonymous (not verified) 94.188.205.168 Bio-Inspired Design Aeronautics Corp 6843 Still Creek Pass I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-08 Hailey Mitchell hailey8.hm@hush.com Bettendorf Iowa United States Mike Owens Chris DeCock Signed (1) The corporation rejects the employers’ liability coverage. Joseph Mitchell aerotech@hush.com President Bettendorf Iowa United States Mike Minnich Chris DeCock Signed
668 2023-05-12 10:14 Anonymous (not verified) 94.188.205.166 Design Drywall Inc. PO Box 457 Tiffin, IA 52340 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-12 Rudy Gonzalez designdrywallinc19@gmail.com Tiffin Johnson Iowa Brad Bower Chris Hay Signed (1) The corporation rejects the employers’ liability coverage. Rudy Gonzalez designdrywallinc19@gmail.com President Tiffin Johnson Iowa Brad Bower Chris Hay Signed
510 2022-07-12 09:13 Anonymous (not verified) 174.198.70.141 Premiere Painting, LLC 865 NE Bobcat Dr Waukee, IA. 50263 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-12 Scott McVay scottkmcvay@live.com Waukee Dallas Iowa Robert Ferguson Christina Pham Signed (1) The corporation rejects the employers’ liability coverage. Scott McVay scottkmcvay@live.con Owner Waukee Dallas Iowa Robert Ferguson Christina Pham Signed
207 2021-03-16 08:34 Anonymous (not verified) 63.152.54.231 Iowa Express Delivery Service Inc. 4021 Old Ferry Road I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-16 Karen Stearns iowaexpressdelivery@gmail.com Palo Linn United States Jeremiah Morris Christina Stearns Signed (1) The corporation rejects the employers’ liability coverage. Karen Stearns iowaexpressdelivery@gmail.com Self Palo Linn United States Jeremiah Morris Christina Stearns Signed
303 2021-08-06 10:12 Anonymous (not verified) 173.28.219.60 Travis Systems, Inc. 2060 Lynncrest Dr I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-06 Travis Remmert travis@travissystems.com Coralville IA United States Michelle Remmert Christine Douglas Signed (1) The corporation rejects the employers’ liability coverage. Travis Remmert travis@travissystems.com President & CEO Coralville IA United States Michelle Remmert Christine Douglas Signed
632 2023-03-22 13:44 Anonymous (not verified) 94.188.205.177 Midwest Home Solutions Inc 150 Light Rd., Lisbon, IA 52253 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-22 Ean Michael Caskey ean_caskey@hotmail.com Lisbon Linn IA Trista Leigh Schaffner Christopher Ray Schaffner Signed (1) The corporation rejects the employers’ liability coverage. Ean Michael Caskey ean_caskey@hotmail.com President Lisbon Linn Iowa Trista Leigh Schaffner Christopher Ray Schaffner Signed
450 2022-04-20 13:42 Anonymous (not verified) 96.85.81.137 D&K Harvesting Inc. P.o Box 1347 LaBelle Fl 33975 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-20 James Larry Marsh Jr larrym3041@aol.com Fort myers Lee Florida Anita Coronado Christy Pequeno Signed (2) The corporation declines to reject the employers’ liability coverage. James Larry Marsh Jr larrym3041@aol.com Owner Fort myers Lee Florida Anita Coronado Christy Puequeno Signed
675 2023-05-24 07:55 Anonymous (not verified) 94.188.207.223 Sierra Roofing 401 W 15th Street West Liberty, IA 52776 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-24 Abraham Granjeno Sierra sierraroofing@gmail.com West Liberty Muscatine Iowa Cody Thorpe Claudia Venable Signed (1) The corporation rejects the employers’ liability coverage. Abraham Granjeno Sierra sierraroofing@gmail.com Owner/Self West Liberty Muscatine Iowa Cody Thorpe Claudia Venable Signed
297 2021-07-30 11:05 Anonymous (not verified) 165.225.60.212 Love Tap Racing LLC 1122 Sunset Ave, Kelley, IA 50134 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-07-30 Timothy Love tiredemon@gmail.com Kelley Story IA Katie Frame Cody Jones Signed (1) The corporation rejects the employers’ liability coverage. Timothy Love tiredemon@gmail.com Owner Ames Story IA Katie Frame Cody Jones Signed
298 2021-07-30 11:05 Anonymous (not verified) 165.225.60.212 Love Tap Racing LLC 1122 Sunset Ave, Kelley, IA 50134 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-07-30 Laura Love tiredemon@gmail.com Kelley Story IA Katie Frame Cody Jones Signed (1) The corporation rejects the employers’ liability coverage. Laura Love tiredemon@gmail.com Owner Ames Story IA Katie Frame Cody Jones Signed
378 2022-01-03 15:16 Anonymous (not verified) 217.180.230.157 True360, Inc. 1805 Collaboration Place, Suite 1300, Ames, Iowa 50010 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-03 Christopher James chris@true-360.com Ames Iowa United States Jesse Kisker Cody Kapka Signed (1) The corporation rejects the employers’ liability coverage. Christopher James chris@true-360.com President and Chief Executive Officer Ames Iowa United States Jesse Kisker Cody Kapka Signed
119 2020-09-28 10:43 Anonymous (not verified) 174.213.149.6 Ddp construction 1923 63rd st, des moines ,ia 50322 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-28 Dustin a perry perrythedustin@gmail.com Urbandale Polk Iowa Lucas jackson Cody roth Signed (1) The corporation rejects the employers’ liability coverage. Smith Kenyon insurance smithkenyon@yahoo.com Agent Urbandale Polk Ia Lucas jackson Cody roth Signed
334 2021-09-14 16:24 Anonymous (not verified) 67.129.252.2 Nextec 4050 Westmark Drive, Dubuque, Iowa 52002 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-14 Susan Kern skern@kendallhunt.com Dubuque Dubuque Iowa Paul Kern Matthew Johnston Signed (1) The corporation rejects the employers’ liability coverage. Greg Feltes gfeltes@westmarkdevelopment.com Officer Dubuque Dubuque Iowa Dana Feltes Cole Feltes Signed
500 2022-06-22 15:55 Anonymous (not verified) 206.125.132.254 Cozad Trucking Inc 2272 W River Dr, Davenport, IA 52802 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-22 David Cozad jeepd856@gmail.com Davenport Scott Iowa Brett Nelson Colleen Heiser Signed (1) The corporation rejects the employers’ liability coverage. David Cozad jeepd856@gmail.com Owner Davenport Scott IA Brett Nelson Colleen Heiser Signed
873 2024-01-26 12:02 Anonymous (not verified) 94.188.207.224 Bowlerama, Inc. 1313 East Diehl St. Des Moines, IA 50315 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-26 Michael Klimpel Klimpel@aol.com Rosemount MN United States Eric Stahl Connie Hill Signed (2) The corporation declines to reject the employers’ liability coverage. Michael Klimpel Klimpel@aol.com President Rosemount MN United States Eric Stahl Connie Hill Signed
193 2021-03-02 11:32 Anonymous (not verified) 50.83.72.164 4 corners drywall 532 w 15 st, Davenport, iowa 52803 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2021-03-02 Phillip hoxsey Phillhoxsey81@gmail.com Davenport Scott Iowa Donivan hoxsey Connor ruge Signed (2) The corporation declines to reject the employers’ liability coverage. Phillip hoxsey Phillhoxsey81@gmail.com Owner Davenport Scott Iowa Donivan hoxsey Connor ruge Signed
194 2021-03-02 11:42 Anonymous (not verified) 50.83.72.164 D’s Drywall 1217 n Blanchard st I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2021-03-02 Donivan hoxsey hdonivan@gmail.com Davenport Scott Iowa Phillip hoxsey Connor ruge Signed (2) The corporation declines to reject the employers’ liability coverage. Donivan hoxsey hdonivan@gmail.com Owner Davenport Scott Iowa Phillip hoxsey Connor ruge Signed
663 2023-05-03 12:53 Anonymous (not verified) 94.188.205.177 Seven Oaks Recreation 1086 222nd Dr., Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-03 Joel Bryan joel@sevenoaksrec.com Ogden Boone United States Anthony Calek Craig Christensen Signed (1) The corporation rejects the employers’ liability coverage. Sara Bryan sara@sevenoaksre.com Director/Vice-President/Secretary Boone Boone United States Anthony Calek Craig Christensen Signed
664 2023-05-03 12:54 Anonymous (not verified) 94.188.205.174 Seven Oaks Recreation 1086 222nd Dr., Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-03 Sara Bryan sara@sevenoaksrec.com Ogden Boone Iowa Anthony Calek Craig Christensen Signed (1) The corporation rejects the employers’ liability coverage. Sara Bryan sara@sevenoaksre.com Director/Vice-President/Secretary Boone Boone United States Anthony Calek Craig Christensen Signed
665 2023-05-03 12:54 Anonymous (not verified) 94.188.205.169 Seven Oaks Recreation 1086 222nd Dr., Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-03 Joel Bryan joel@sevenoaksrec.com Ogden Boone Iowa Anthony Calek Craig Christensen Signed (1) The corporation rejects the employers’ liability coverage. Sara Bryan sara@sevenoaksre.com Director/Vice-President/Secretary Boone Boone United States Anthony Calek Craig Christensen Signed
371 2021-12-09 11:03 Anonymous (not verified) 216.81.176.153 Concentric International Inc. 1901 Bell Ave Ste 18, Des Moines, IA 50315-1067 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-12-09 Tracey Ball tball@ruan.com Urbandale IA United States Jackie Walker Craig Gesme Signed (1) The corporation rejects the employers’ liability coverage. Tracey Ball tball@ruan.com Treasurer Urbandale IA United States Jackie Walker Craig Gesme Signed
558 2022-10-17 09:25 Anonymous (not verified) 67.22.198.94 Baker Irrigation Inc. 2621 310th St. Rock Valley, IA 51247 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-10-17 Daniel Baker dan@bakerirrigationia.com Rock Valley Sioux Iowa Jesse Niemeyer Crystal Brink Signed (1) The corporation rejects the employers’ liability coverage. Alex DeJager alex@bakerirrigationia.com Co-Owner Rock Valley Sioux Iowa Jesse Niemeyer Crystal Brink Signed
774 2023-09-21 10:21 Anonymous (not verified) 94.188.205.167 Tri State Trucking LLC 47282 US Hwy 20 Atkinson, NE 68713 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-09-21 Casey Schaaf casey@tri-statetrucking.com Atkinson Holt NE Angela Schaaf Crystal Osborne Signed (1) The corporation rejects the employers’ liability coverage. Casey Schaaf casey@tri-statetrucking.com Owner Atkinson Holt NE Angela Schaaf Crystal Osborne Signed
599 2023-02-13 12:14 Anonymous (not verified) 94.188.207.227 Christian Gilbert 3174 HWY F48 W. Newton, IA 50208 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-02-13 Christian Gilbert christian.gilbert14@gmail.com Newton Jasper Iowa Marcus Thompson Crystal Ward Signed (1) The corporation rejects the employers’ liability coverage. Christian Gilbert christian.gilbert14@gmail.com self Newton Jasper Iowa Marcus Thompson Crystal Ward 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
309 2021-08-16 10:36 Anonymous (not verified) 71.86.215.206 st ansgar historic school project, inc po box 52 st ansgar IA 50472 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-16 tammi kofoot tammykofoot@gmail.com st ansgar mitchell ia julie thome dale blakestad Signed (1) The corporation rejects the employers’ liability coverage. tyler mckinley tbmckinley@gmail.com treasurer rochester mn olmsted julie thome dale blakestad Signed
310 2021-08-16 10:37 Anonymous (not verified) 71.86.215.206 st ansgar historic school project, inc po box 52 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-16 dana wold dawold@woldinc.com st ansgar mitchell ia julie thome dale blakestad Signed (1) The corporation rejects the employers’ liability coverage. tyler mckinley tbmckinley@gmail.com treasurer rochester olmsted mn julie thome dale blakestad Signed
460 2022-05-02 10:00 Anonymous (not verified) 73.9.3.194 ERLIN AVILA INC 1940 N GREEN LN APT 2A PALATINE IL 60074 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-02 ERLIN AVILA INC dianalcandelaria@aol.com PALATINE COOK IL DIANA CANCELARIA DALILA VILLEGAS Signed (1) The corporation rejects the employers’ liability coverage. ERLIN AVILA TORREZ dianalcandelaria@aol.com PRESIDENT PALATINE Illinois United States Diana L Candelaria DALILA VILLEGAS Signed
869 2024-01-25 14:19 Anonymous (not verified) 94.188.207.227 Christensen Leasing LLC 1008 Brooks North Lane I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-25 Michael Christensen cconmichael@gmail.com Okoboji Dickinson Iowa Roger Christensen Dan Christensen Signed (1) The corporation rejects the employers’ liability coverage. Michael Christensen cconmichael@gmail.com Owner Okoboji Dickinson Iowa Roger Christensen Dan Christensen Signed
922 2024-03-19 13:19 Anonymous (not verified) 94.188.205.169 Stephen D. Seils 314 East Clevland Street, New London, IA 52645 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-09 Stephen Dwight Seils sdseils43@gmail.com New London Henry Iowa Josh Horn Dan Hollingsworth Signed (1) The corporation rejects the employers’ liability coverage. Stephen D. Seils sdseils43@gmail.com Owner New London Henry Iowa Josh Horn Dan Hollingsworth Signed
301 2021-08-04 10:05 Anonymous (not verified) 63.142.48.170 Vision Homes Inc 2566 Ivanhoe Rd. 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. 2021-07-02 DeeAnn Nejdl chucknejdl@gmail.com Cedar Rapids Linn Iowa Melanie Heitman Dan Lillis Signed (1) The corporation rejects the employers’ liability coverage. DeeAnn Nejdl chucknejdl@gmail.com Owner Cedar Rapids Linn Iowa Melanie Heitman Dan Lillis Signed
302 2021-08-04 10:08 Anonymous (not verified) 63.142.48.170 Vision Homes Inc 2566 Ivanhoe Rd. 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. 2021-07-02 Charles Nejdl chucknejdl@gmail.com Cedar Rapids Linn Iowa Melanie Heitman Dan Lillis Signed (1) The corporation rejects the employers’ liability coverage. Charles Nejdl chucknejdl@gmail.com Vice President Cedar Rapids Linn Iowa Melanie Heitman Dan Lillis Signed
893 2024-02-22 10:29 Anonymous (not verified) 94.188.207.226 Sierra Roofing 401 W 15th Street West Liberty, IA 52776 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-22 Abraham Granjeno Sierra absierra89@gmail.com West Liberty Muscatine Iowa Claudia Venable Dan Saunders Signed (1) The corporation rejects the employers’ liability coverage. Abraham Granjeno Sierra absierra89@gmail.com Owner/Self West Liberty Muscatine Iowa Claudia Venable Dan Saunders Signed
698 2023-06-21 07:46 Anonymous (not verified) 94.188.207.223 Jesus Rodriguez 2210 E. Rose Avenue Apt. 30 Des Moines, Iowa 50320 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-21 Jesus Rodriguez jesus.jr4514@gmail.com Des Moines Polk Iowa Veronica Rodriguez Daniel Gallardo Signed (1) The corporation rejects the employers’ liability coverage. Jesus Rodriguez jesus.jr4514@gmail.com Owner Des Moines Polk Iowa Veronica Rodriguez Daniel Gallardo Signed
639 2023-03-27 12:24 Anonymous (not verified) 94.188.207.230 Midwest Home Solutions Inc 150 Light Road, Lisbon, IA 52253 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-16 Ean Caskey ean_caskey@hotmail.com Lisbon Linn IA Corey Scott Daniel Munro Signed (1) The corporation rejects the employers’ liability coverage. Daniel Munro danielmunro@gmail.com Agent Oceanside CA United States Corey Scott Daniel Munro Signed
477 2022-05-19 11:49 Anonymous (not verified) 172.86.13.54 BOLT HOLDINGS Inc. and Holt Precision dba Holt Bladeworks and Holt Kinetic Solutions 3230 N. Center Point Rd Unit 204, Marion, IA 52302 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-19 Ben Congleton Ben@holtkineticsolutions.com Cedar Rapids Linn Iowa Lisa Gleason Angey Holt Signed (1) The corporation rejects the employers’ liability coverage. Lisa Gleason Lisa@holtkineticsolutions.com General Manager Marion Linn Iowa Lisa Gleason Danielle Congleton Signed
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
306 2021-08-11 17:03 Anonymous (not verified) 208.73.53.194 Dave Sturges Trucking Inc 16244 170th St. Rockwell, IA 50469 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-11 Joseph d sturges sturgtrucking@gmail.com Rockwell, IA Cerro Gordo IA Connie Downing Darc Schropshire Signed (1) The corporation rejects the employers’ liability coverage. Brian Sturges briansturges@netins.net President Rockwell, Ia Cerro Gordo IA Connie Downing Darc Schropshire 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
138 2020-11-24 14:11 Anonymous (not verified) 173.215.17.41 Dohrmann Enterprises, Inc 2478 260th Ave. DeWitt, Iowa 52742 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-11-24 Joel Dohrmann dohrmannpnh@gmail.com DE WITT Clinton IA Susanne Owen Daron Oberbroecking Signed (1) The corporation rejects the employers’ liability coverage. Susanne Owen sowen@ohnward.com none Camanche Clinton Iowa Joel Dohrmann Daron Oberbroecking Signed
145 2020-12-18 07:54 Anonymous (not verified) 173.215.16.15 Dohrmann Enterprises Inc 2652 350th Ave DeWitt, IA 52742 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-18 Tom Dohrmann dohrmannpnh@gmail.com DeWitt Clinton Iowa Susanne Owen Daron Oberbroeckling Signed (1) The corporation rejects the employers’ liability coverage. Tom Dohrmann dohrmannpnh@gmail.com Owner DeWitt Clinton Iowa Susanne Owen Daron Oberbroeckling Signed
660 2023-04-26 07:56 Anonymous (not verified) 94.188.207.227 Darrin Hearn DBA GoodCauseMinis 445 Onyx 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. 2023-04-26 Darrin Hearn goodcauseminis@gmail.com Marion IA United States Darrin Hearn Darrin Hearn Signed (1) The corporation rejects the employers’ liability coverage. Darrin Hearn goodcauseminis@gmail.com owner Marion IA United States Darrin Hearn Darrin Hearn Signed
592 2023-01-22 11:29 Anonymous (not verified) 216.106.211.176 Trackside Service & Repair Inc. 205 Main St. Alvord, IA 51230 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-22 Renee J Klarenbeek dkranch@alliancecom.net Rock Rapids Iowa United States Steve C. Green Darwyn G. Klarenbeek Signed (1) The corporation rejects the employers’ liability coverage. Darwyn G. Klarenbeek trackside@alliancecom.net Owner Rock Rapids Lyon IA Steve C. Green Darwyn G. Klarenbeek Signed
587 2023-01-09 10:04 Anonymous (not verified) 173.27.230.122 Hatfield Co Inc 307 E 20th St Box 185 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-09 Brenda Hatfield brenmarie137.bh@gmail.com Lovilia IA United States Jerry Griffin Dave Chesnut Signed (1) The corporation rejects the employers’ liability coverage. Boyle and Henderson joycem@boyleandhenderson.com Accountant Oskaloosa Marion Iowa Jerry Griffin Dave Chesnut Signed
24 2020-01-02 09:12 Anonymous (not verified) 207.191.194.182 Waukee CabinetWorks LLC 70 SE Laurel St, Waukee IA 50263 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2019-12-23 Amy Balm chris.rappe@waukeecabinetworks.com Waukee Dallas Iowa Chris Andrews Dave Creighton Sr Signed (1) The corporation rejects the employers’ liability coverage. Chris Rappe chris.rappe@waukeecabinetworks.com Operations Manager Waukee Dallas IA Chris Andrews Dave Creighton SR Signed
25 2020-01-02 09:17 Anonymous (not verified) 207.191.194.182 Waukee CabinetWorks LLC 70 SE Laurel St, Waukee IA 50263 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2019-12-23 Jason Balm chris.rappe@waukeecabinetworks.com Waukee Dallas Iowa Chris Andrews Dave Creighton Sr Signed (1) The corporation rejects the employers’ liability coverage. Chris Rappe chris.rappe@waukeecabinetworks.com Operations Manager Waukee Dallas Iowa Chris Andrews Dave Creighton SR Signed
967 2024-05-01 06:30 Anonymous (not verified) 94.188.207.224 Cael Gulrud 206 W Main St Calmar, IA, 52132 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-01 Brandon Gulrud mojopants21@gmail.com Waterloo Blackhawk IA Victoria Bacon-Ortiz David Gulrud Signed (1) The corporation rejects the employers’ liability coverage. Cael Gulrud gulrud8728@gmail.com Owner Calmar Winneshiek IA Victoria Bacon-Ortiz David Gulrud Signed
435 2022-03-28 07:14 Anonymous (not verified) 75.162.66.125 Jenkins Electric LLC 304 E North St. Prairie City, IA I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-28 Colten Jenkins colten@jenkins-electric.com Prairie City Jasper Iowa Kristin Jenkins David Jennings Signed (1) The corporation rejects the employers’ liability coverage. Colten Jenkins colten@jenkins-electric.com Owner Prairie City Jasper Iowa Kristin Jenkins David Jennings Signed
88 2020-06-10 11:36 Anonymous (not verified) 173.28.7.32 DMG INSTALLATIONS INC 5534 NE 17TH ST #4 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-06-10 DAVID PAUL DUNLAP HAYDAVE@AOL.COM DES MOINES POLK IOWA JASON DAVID MUSSO CLIFFORD LEE BAKER Signed (1) The corporation rejects the employers’ liability coverage. CLIFF BAKER CLBAKER@MEDIACOMBB.NET PRESIDENT ALTOONA POLK IOWA JASON DAVID MUSSO DAVID PAUL DUNLAP Signed
89 2020-06-10 11:42 Anonymous (not verified) 173.28.7.32 DMG INSTALLATIONS INC 5534 NE 17TH ST #4 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-06-10 JASON DAVID MUSSO JMUSSO74@GMAIL.COM BONDURANT POLK IOWA DAVID PAUL DUNLAP CLIFFORD LEE BAKER Signed (1) The corporation rejects the employers’ liability coverage. CLIFFORD LEE BAKER CLBAKER@MEDIACOMBB.NET PRESIDENT ALTOONA POLK IOWA JASON DAVID MUSSO DAVID PAUL DUNLAP Signed
90 2020-06-10 11:46 Anonymous (not verified) 173.28.7.32 DMG INSTALLATIONS INC 5534 NE 17TH ST #4 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-06-10 CLIFFORD LEE BAKER CLBAKER@MEDIACOMBB.NET ALTOONA POLK IOWA DAVID PAUL DUNLAP JASON DAVID MUSSO Signed (1) The corporation rejects the employers’ liability coverage. CLIFFORD LEE BAKER CLBAKER@MEDIACOMBB.NET PRESIDENT ALTOONA POLK IOWA JASON DAVID MUSSO DAVID PAUL DUNLAP Signed
527 2022-08-18 12:44 Anonymous (not verified) 75.146.219.201 James F. Valentine, Inc. 300 Thomas Avenue, Bldg 401, Williamstown, NJ 08094 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-08-18 James F. Valentine jvalentine@valentineassoc.com Williamstown Gloucester New Jersey Kim Vona Dawn Souder Signed (1) The corporation rejects the employers’ liability coverage. James F Valentine jvalentine@valentineassoc.com Owner Williamstown Gloucester New Jersey Kim Vona Dawn Souder Signed
528 2022-08-22 15:57 Anonymous (not verified) 75.146.219.201 James F. Valentine 300 Thomas Avenue, Bldg 401, Williamstown, NJ 08094 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-08-22 James F. Valentine jvalentine@valentineassoc.com Williamstown Gloucester New Jersey Kim Vona Dawn Souder Signed (1) The corporation rejects the employers’ liability coverage. James F. Valentine jvalentine@valentineassoc.com Owner Williamstown Gloucester New Jersey Kim Vona Dawn Souder Signed
178 2021-02-13 00:06 Anonymous (not verified) 172.58.87.80 All Cut Lawncare and Landscaping LLC 3506 Glover Ave. Des Moines Iowa 50315 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-02-12 Michael David Money moneymichael811@gmail.com Des Moines Polk Iowa Diana Jennings Deanna L Phagan Signed (1) The corporation rejects the employers’ liability coverage. Michael David Miney mineymichael811@gmail.com Owner and President Des Moines Polk Iowa Diana Jennings Deanna L Phagan Signed
233 2021-04-13 10:35 Anonymous (not verified) 172.83.18.1 Skyway Inc 7030 27th Way, Clear Lake, IA 50428 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-06 Brad Thompson mary@skywaypropertyinspections.com Clear Lake Cerro Gordo Iowa Becky Plagge Deb Otto Signed (1) The corporation rejects the employers’ liability coverage. Brad Thompson mary@skywaypropertyinspections.com Owner Clear Lake Cerro Gordo Iowa Becky Plagge Deb Otto Signed
234 2021-04-13 10:37 Anonymous (not verified) 172.83.18.1 Skyway Inc 7030 27th Way, Clear Lake, IA 50428 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-06 Mary Thompson mary@skywaypropertyinspections.com Clear Lake Cerro Gordo Iowa Becky Plagge Deb Otto Signed (1) The corporation rejects the employers’ liability coverage. Brad Thompson mary@skywaypropertyinspections.com Owner Clear Lake Cerro Gordo Iowa Becky Plagge Deb Otto Signed
205 2021-03-10 09:55 Anonymous (not verified) 173.27.221.9 Tri State Archery, Inc 2100 White St, Dubuque IA 52001 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-14 Denise Udelhofen office@tristateoutdoors.net Dubuque Dubuque Iowa Phillip J Meyer Debbie Meyer Signed (2) The corporation declines to reject the employers’ liability coverage. Jeff Udelhofen office@tristateoutdoors.net President Dubuque Dubuque IA Phillip Meyer Debbie Meyer Signed
299 2021-08-02 10:55 Anonymous (not verified) 97.125.35.240 L:ion BUilder Construction,, INC 1705 E 32nd St 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. 2021-07-24 Carlos E Mondoza-Gutierrez gutierrezce1992@icloud.com Des Moines Polk Iowa Debra Stratton Juana M.R. Signed (1) The corporation rejects the employers’ liability coverage. Carlos E Mendoz-Gutierrez gutierrezce1992@icloud.com self Des Moines Polk Iowa Juan M. R. Debra Stratton Signed
300 2021-08-03 12:43 Anonymous (not verified) 97.125.35.240 Every Solutions Drywall INC 713 SE 7th St Des Moines, Iowa 50309 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-03 Luis Hernandez everysolutiondrywainc@yahoo.com Des Moines Polk Iowa Kelly Denger Debra Stratton Signed (1) The corporation rejects the employers’ liability coverage. Luis Hernandez everysoloutiondrywainc@yahoo.com Owner Des Moines Polk Ia Kelly Denger Debra Stratton Signed
613 2023-02-27 14:19 Anonymous (not verified) 94.188.205.169 Kevin Moore Professional Carpentry 2000 s. 16th st Burlington iowa 52601 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-02-27 Keivn W. Moore imkwmoore@gmail.com Burlington Des Moines Iowa Kevin Moore DeeAnn Howard Signed (1) The corporation rejects the employers’ liability coverage. Kevin W Moore imkwmoore@gmail.com Owner Burlington DesMoines Iowa Kevin Moore DeeAnn Howar Signed
595 2023-01-31 09:35 Anonymous (not verified) 50.83.168.191 Lumos Electric, Inc DBA Dave Bessine Electric 705 Valley Street, Burlington, Iowa, 52601 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-31 Shawna Brown recdbessine@qwestoffice.net Burlington iowa United States Shelly Knight DeeAnn Howard Signed (1) The corporation rejects the employers’ liability coverage. Tim Brown recdbessine@qwestoffice.net Vice-President Burlington iowa United States Shelly Knight DeeAnn Howard Signed
522 2022-07-27 21:58 Anonymous (not verified) 173.25.135.5 Kokemiller construction 5995 Martin drive I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-27 Jessie james kokemiller jkokemo3@gmail.com Pleasant Hill Polk Ia Jonathon Hays Demi Muchmore Signed (1) The corporation rejects the employers’ liability coverage. Jessie James kokemiller jkokemo3@gmail.com President Pleasant Hill Polk Ia Jonathon Hays Demi Muchmore Signed
930 2024-03-21 20:44 Anonymous (not verified) 94.188.207.229 Southeast Iowa Precision Painting 714 Lincoln St Ainsworth IA 52201 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-21 Kirby Jay Shetler kirbyshetler@gmail.com Ainsworth Washington Iowa Kirby Shetler Demi Shetler Signed (1) The corporation rejects the employers’ liability coverage. Southeast Iowa Precision Painting kirbyshetler@gmail.com Owner Ainsworth Washington Iowa Kirby Shetler Demi Shetler Signed
753 2023-08-21 14:21 Anonymous (not verified) 94.188.205.174 NexLevelMoving 1186 Capital Dr Sw, Cedar Rapids I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-23 Ethan Daniel Sailer ethan.sailer@hscsi.net Cedar Rapids Linn County Iowa Penny Sailer Denis Sailer Signed (1) The corporation rejects the employers’ liability coverage. Ethan Daniel Sailer ethan.sailer@hscsi.net Self Cedar Rapids Linn County Iowa Penny Sailer Denis Sailer Signed
530 2022-09-02 13:17 Anonymous (not verified) 173.20.146.6 Nicci Keck LLC 1107 Pheasant Valley St, Iowa City, IA 52246 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-02 Nicole Keck niccikeckllc@gmail.com Iowa City Johnson Iowa Evangeline Kadera Denise Kandel Signed (1) The corporation rejects the employers’ liability coverage. Nicole Keck niccikeckllc@gmail.com Managing Member/Owner/President Iowa City Johnson Iowa Evangeline Kadera Denise Kandel Signed
531 2022-09-02 13:19 Anonymous (not verified) 173.20.146.6 Nicci Keck LLC 1107 Pheasant Valley St, Iowa City, IA 52246 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-02 Benjamin Darbro darbrob@gmail.com Iowa City Johnson Iowa Evangeline Kadera Denise Kandel Signed (1) The corporation rejects the employers’ liability coverage. Nicole Keck niccikeckllc@gmail.com Managing Member/Owner/President Iowa City Johnson Iowa Evangeline Kadera Denise Kandel Signed
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
242 2021-04-21 13:27 Anonymous (not verified) 198.14.211.149 Centerville Greenhouses 418 N. 5th Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-21 Alexander Joseph Lind alex@centervillegreenhouses.com Centerville IA United States John Douglas Hurley Dennis James Peters Signed (1) The corporation rejects the employers’ liability coverage. Peter Michael Lind peter@centervillegreenhouses.com President Centerville IA United States John Douglas Hurley Dennis James Peters Signed
243 2021-04-21 13:29 Anonymous (not verified) 198.14.211.149 Centerville Greenhouses 418 N. 5th Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-21 Peter Michael Lind peter@centervillegreenhouses.com Centerville IA United States John Douglas Hurley Dennis James Peters Signed (1) The corporation rejects the employers’ liability coverage. Alexander Joseph Lind alex@centervillegreenhouses.com Vice President Centerville IA United States John Douglas Hurley Dennis James Peters Signed
536 2022-09-16 09:56 Anonymous (not verified) 65.155.194.4 Tectum Construction and Roofing Inc. 1623 Thetford Cir Orlando FL 32824 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-16 Segundo Sanchez fsanchez@tectumconstruction.com Orlando Fl United States Chris Becker Dereck Bolten Signed (1) The corporation rejects the employers’ liability coverage. Segundo Sanchez fsanchez@tectumconstruction.com CEO ORLANDO Orange Florida Chris Becker Dereck Bolten Signed
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
103 2020-07-23 09:23 Anonymous (not verified) 184.80.177.137 Jacob Reiff 15738 N Cascade Rd - 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. (2) I decline to reject the employer’s liability coverage. 2020-07-23 Jacob Reiff jheims@engish-insurance.com Peosta, Dubuque Iowa Joyce Heims Derrick Parsons Signed (2) The corporation declines to reject the employers’ liability coverage. Joyce Heims jheims@english-insurance.com owner Peosta Dubuque Iowa Joyce Heims Derrick Parsons Signed
108 2020-08-19 09:39 Anonymous (not verified) 184.80.177.137 Michelle's Vocational Placement LLC 2642 Farragut Pl., Davenport, IA 52804 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-08-18 Tara Rommel jheims@engish-insurance.com Davenport Scott Iowa Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed
115 2020-09-08 09:48 Anonymous (not verified) 184.80.177.137 Beyond Builders LLC 206 Culver Road NE, Hopkinton, IA 52237 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-08 John Eiben ginger_bread_man@msn.com HOPKINTON Delaware IA Derrick Parsons Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. John Eiben ginger_bread_man@msn.com Owner Hopkinton Delaware Iowa Derrick Parsons Derrick Parsons Signed
279 2021-06-23 10:41 Anonymous (not verified) 184.80.177.137 AA Breeders P.O. Box 470 - Epworth, IA 52045 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-06-22 Justin Curtis jheims@english-insurance.com Epworth Dubuque Iowa Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. AA Breeders - Justin Curtis jheims@english-insurance.com self Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed
384 2022-01-06 16:01 Anonymous (not verified) 184.80.177.137 Top R Farms 1199 Woodland Drive - Dyersville, IA 52040 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-06 Robert Fangmann 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 agent Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed
388 2022-01-11 13:58 Anonymous (not verified) 184.80.177.137 Demmer Construction 203 Michigan Ave - Farley, IA 52046 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-12-21 Charlie Demmer jheims@english-insurance.com Dyersville Dubuque IA Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Jenny Osburn jheims@english-insurance.com agent Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed
389 2022-01-11 14:02 Anonymous (not verified) 184.80.177.137 Demmer Construction 203 Michigan Ave - Farley, IA 52046 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-05-12 Charlie Demmer jheims@english-insurance.com Farley Dubuque Iowa Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Jenny Osburn jheims@english-insurance.com agent Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed
455 2022-04-27 14:04 Anonymous (not verified) 184.80.177.137 Classic Custom Cabinets, Inc 31931 Bries Drive , Dyersville, IA 52040 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-27 Mike Then jheims@english-insurance.com Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Joyce Heims jheims@english-insurance.com agent Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed
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
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
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
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
532 2022-09-07 12:42 Anonymous (not verified) 217.180.226.147 Practical Farmers of Iowa 1615 Golden Aspen Dr., Suite 101, Ames, IA 50010 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-07 Jonathan Bakehouse jon@mapleedgefarm.com Hastings Mills Iowa Jeanne-Marie Bakehouse DeWayne Kroledge Signed (1) The corporation rejects the employers’ liability coverage. Sally Worley sally@practicalfarmers.org Executive Director Ames Story United States Jeann-Marie Bakehouse DeWayne Kroledge Signed
83 2020-05-20 12:34 Anonymous (not verified) 108.171.131.188 North Iowa Custom Seamless Guttering, Inc PO Box 512, 1300 2nd Ave S, Clear Lake, Iowa 50428 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-05-20 Keith E Main keithmaincsg@hotmail.com Clear Lake Cerro Gordo Iowa Lloyd L Heinselman Diane K Harrington Signed (1) The corporation rejects the employers’ liability coverage. Keith E Main keithmaincsg@hotmail.com President Clear Lake Cerro Gordo Iowa Lloyd L Heinselman Diane K Harrington Signed
37 2020-02-06 15:49 Anonymous (not verified) 100.42.95.100 Matthew Saboe 2075 330th St, Spencer IA 51301 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-02-06 Matthew Saboe galmgirl@gmail.com Spencer Clay IA Laura Ashley Tauscher Diane Kimball Signed (1) The corporation rejects the employers’ liability coverage. Matthew Saboe galmgirl@gmail.com Owner Spencer Clay IA Laura Ashley Tauscher Diane Kimball 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
940 2024-04-03 07:49 Anonymous (not verified) 94.188.205.167 Wildride Trucking 3261 old river rd sw. Cedar Rapids Ia I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-04-03 David mckee wildride1969@gmail.com Cedar Rapids Lynn Ia Valerie mckee Dillon Williams Signed (1) The corporation rejects the employers’ liability coverage. Dave mckee wildride1969@gmail.com Owner Cedar Rapids Lynn Ia Valerie mckee Dillon Williams Signed
913 2024-03-07 07:46 Anonymous (not verified) 94.188.207.229 Fair Trade Acoustical Ceiling Services 3837 5th 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. 2024-03-07 Mathew Bingaman Bingaman.matthew1@gmail.com Des Moines Polk Iowa Jamie Rose Dmitri Mejia Signed (1) The corporation rejects the employers’ liability coverage. Mathew Bingaman Bingaman.matthew1@gmail.com Owner Des Moines Polk Iowa Jamie Rose Dmitri Mejia Signed
282 2021-06-30 12:31 Anonymous (not verified) 204.155.61.217 Stout Roofing Inc 1200 Ash St, Dallas Center, IA 50063 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-06-30 Jacob Stout jacobstout@hailmayday.com Dallas Center Dallas County IA Ashley Kraft Docusign Signed (1) The corporation rejects the employers’ liability coverage. Jacob Stout jacobstout@hailmayday.com Owner Dallas center Dallas IA Ashley Kraft Docusign Signed
296 2021-07-29 08:51 Anonymous (not verified) 204.155.61.217 Blaine Management Inc 660 NE Dellwood Dr Apt 17, Waukee, IA 5063 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-07-29 Brent Ott brent@hailmayday.com Prior Lake Scott MN Ashley Kraft DocuSign Signed (1) The corporation rejects the employers’ liability coverage. Brent Ott Brent@hailmayday.com Owner Prior Lake Scott MN Ashley Kraft Docusign Signed
263 2021-05-06 15:18 Anonymous (not verified) 174.243.113.232 Agronomic Solutions 908 E Dubuque St Quasqueton IA 52326 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-05-06 Brandy Hodges mapping@agsolutionsinc.net Coon Rapids IA United States Jacki Sloss Don Sloss Signed (1) The corporation rejects the employers’ liability coverage. Friday Insurance doug.miller@fridayinsurance.net agent Osceola Clarke IA Jacki Sloss Don Sloss Signed
289 2021-07-22 17:47 Anonymous (not verified) 172.58.83.5 Javier Construction INC 2503 canyon 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. 2021-07-22 Javier Aldana Fuentes Javierconstruction88@gmail.com Cedar Rapids Linn Iowa DaZsa Aldana Donya Fleetwood Signed (1) The corporation rejects the employers’ liability coverage. Javier Aldana Fuentes Javierconstruction88@gmail.com owner Cedar Rapids LInn Iowa DaZsa Aldana Donya Fleetwood 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
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
186 2021-02-24 14:35 Anonymous (not verified) 216.51.194.37 Estherville Aviation, Inc. 1672 425th Ave, Estherville, IA 51334 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-02-24 Paul Abrams Slaughter estavtn@yourstarnet.net Estherville Emmet Iowa Jordan Lampman Dwayne Hoss Signed (1) The corporation rejects the employers’ liability coverage. Paul Abrams Slaughter estavtn@yourstarnet.net President Estherville Emmet Iowa Jordan Lampman Dwayne Hoss Signed
374 2021-12-17 08:19 Anonymous (not verified) 69.63.16.2 AT Construction Inc. 5 Westview Acres NE, Iowa City IA 52240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-12-17 Tomas Acas atconstruction@hotmail.com Iowa City Johnson Iowa Steve Fishman Dyan Kriener Signed (1) The corporation rejects the employers’ liability coverage. Tomas Acas atconstruction@hotmail.com President Iowa City Johnson Iowa Steve Fishman Dyan Kriener Signed
424 2022-03-11 15:36 Anonymous (not verified) 69.63.16.2 BR Flynn Co Inc 16756 Corey Daniel Ct, Dubuque, IA 52001 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-11 Bruce R Flynn br.flynn4@gmail.com Dubuque Dubuque Iowa Rick Meyer Dyan Kriener Signed (1) The corporation rejects the employers’ liability coverage. Bruce R Flynn br.flynn4@gmail.com President Dubuque Dubuque IA Rick Meyer Dyan Kriener Signed
619 2023-03-06 09:02 Anonymous (not verified) 94.188.207.229 Gaytan Framing LLC 4745 NE 27th Ct 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. 2023-03-06 Jose Gaytan jose1988.jg8@gmail.com Des Moines Iowa United States Carla Gaytan Eduardo Vazquez Signed (1) The corporation rejects the employers’ liability coverage. Jose Gaytan jose1988.jg8@gmail.com Owner Des Moines Polk IA Carla Gaytan Eduardo Vazquez Signed
673 2023-05-23 07:07 Anonymous (not verified) 94.188.207.224 Mulgrew Seamless Gutters 12 REMINGTON PARK CIR east dubuque Illinois 61025 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-22 Edward mulgrew Emulgrew78@gmail.com East Dubuque Jo Davis Illinois Mike Venable Claudia Venable Signed (1) The corporation rejects the employers’ liability coverage. Edward mulgrew Emulgrew78@gmail.com Owner East Dubuque Jo Davis Illinois Edward mulgrew Edward c mulgrew Signed
674 2023-05-23 07:08 Anonymous (not verified) 94.188.207.223 Mulgrew Seamless Gutters 12 REMINGTON PARK CIR east dubuque Illinois 61025 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-22 Edward mulgrew Emulgrew78@gmail.com East Dubuque Jo Davis Illinois Mike Venable Claudia Venable Signed (1) The corporation rejects the employers’ liability coverage. Edward mulgrew Emulgrew78@gmail.com Owner East Dubuque Jo Davis Illinois Edward mulgrew Edward c mulgrew Signed
865 2024-01-23 14:32 Anonymous (not verified) 94.188.205.177 Josh Oswald 505 Eisenhower Rd., Osceola, IA 50213 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-23 Joshua Oswald jjoswald47@gmail.com Osceola Clarke Iowa Douglas Eugene Miller Elaine Lee Signed (1) The corporation rejects the employers’ liability coverage. Joshua Oswald jjoswald47@gmail.com Owner/Sole Proprietor Osceola Clarke Iowa Douglas Eugene Miller Elaine Lee Signed
951 2024-04-08 10:59 Anonymous (not verified) 94.188.205.167 McBee Trucking, LLC 5029 HARDING 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. 2024-04-08 Gary McBee accounting@mcbeetrucking.com Prole Warren Iowa Gary McBee Elizabeth Reid Signed (1) The corporation rejects the employers’ liability coverage. GARY MCBEE gary@mcbeetrucking.com Owner PROLE IA United States GARY MCBEE Elizabeth Reid Signed
911 2024-03-02 14:34 Anonymous (not verified) 94.188.205.168 Gerlich Enterprises 2824 Hickory Hills Ln I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-02 Garrett Gerlich paul@gerlich.io Bettendorf scott IA Paul Gerlich Kelsey Gerlich Signed (1) The corporation rejects the employers’ liability coverage. Paul Gerlich paul@gelrich.io Owner Bettendorf Scott Iowa Kelsey Gerlich Elora Gerlich 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
131 2020-11-03 10:26 Anonymous (not verified) 207.32.1.185 Little Bison Childcare Center 404 2nd ST NW Buffalo Center, IA. 50424 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-11-03 Megan C Holland megzholland@live.com Buffalo Center Winnebago Iowa Nicholas D Holland Emily J Angstman Signed (1) The corporation rejects the employers’ liability coverage. Megan C Holland megzholland@live.com Vice President Buffalo Center Winnebago Iowa Nicholas D Holland Emily J Angstman Signed
931 2024-03-21 20:54 Anonymous (not verified) 94.188.207.228 Cnr drywall llc 410 w 6th st muscatine Iowa 52761 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-21 Jair Romo cnrdrywall@gmail.com Muscatine Muscatine Iowa Jordy tenorio Emmanuel Nunez Signed (1) The corporation rejects the employers’ liability coverage. Cnr drywall cnrdrywall@gmail.com Owner Muscatine Muscatine Ia Jordy tenorio Emmanuel Nunez Signed
344 2021-10-07 15:22 Anonymous (not verified) 73.191.238.89 Kleaveland Brothers, Inc c/o 5724 36th Avenue, Ne. Seattle, WA 98105 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-10-07 I. Justin Kleaveland justinqt@comcast.net North Muskegon Muskegon MI Amanda A. Finch Enrika L.F. McGahan Signed (1) The corporation rejects the employers’ liability coverage. I. Justin Kleaveland justinqt@comcast.net Vice President North Muskegon Muskegon MI Amanda A. Finch Enrika L.F. McGahan Signed
343 2021-10-07 15:12 Anonymous (not verified) 73.191.238.89 Kleaveland Brothers, Inc. c/o 5724 36th Avenue NE, Seattle, WA 98105 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-10-07 Michael I. Kleaveland kleaveland@comcast.net Muskegon Muskegon MI Amanda A. Finch Enrika L.F. McGahan Signed (1) The corporation rejects the employers’ liability coverage. Michael I. Kleaveland kleaveland@comcast.net Secretary/Treasurer Muskegon Muskegon MI Amanda A. Finch Enrika L.F. McGahan Signed
35 2020-01-31 14:56 Anonymous (not verified) 96.31.22.239 HOGMILE PORK LLC 2032 220TH ST INWOOD, IOWA 51240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-01-31 GALEN VANDEVEGTE galenvv@alliancecom.net INWOOD LYON IOWA LISA FABER ERIC TEGROOTENHUIS Signed (1) The corporation rejects the employers’ liability coverage. GALEN VANDEVEGTE galenvv@alliancecom.net SELF INWOOD LYON IOWA LISA FABER ERIC TEGROOTENHUIS Signed
36 2020-01-31 14:59 Anonymous (not verified) 96.31.22.239 HOGMILE PORK LLC 2032 220TH ST INWOOD IOWA 51240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-01-31 GLENN VANDEVEGTE glenvv@alliancecom.net INWOOD LYON IOWA LISA FABER ERIC TEGROOTENHUIS Signed (1) The corporation rejects the employers’ liability coverage. GLENN VANDEVEGTE glennvv@alliancecom.net self INWOOD LYON IOWA LISA FABER ERIC TEGROOTENHUIS Signed
341 2021-10-05 13:52 Anonymous (not verified) 98.22.0.231 Randall Roofing, Inc. 1531 Shady Brook Lane, Pella, IA 50219 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2021-10-10 Randall Bernard Jarzombek randy@randallroofs.com Pella Marion Iowa Mark Densmore Erica Clifford Signed (2) The corporation declines to reject the employers’ liability coverage. Randall Bernard Jarzombek randy@randallroofs.com Owner Pella Marion Iowa Mark Densmore Erica Clifford 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
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
328 2021-09-08 08:31 Anonymous (not verified) 97.125.157.23 Dan Petersen Construction 1725 S 14th St, Polk City, IA 50026 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-08 Daniel Petersen danpetersenconstruction@gmail.com Polk City Polk County Iowa Jim McMurray Erik Gramenz Signed (1) The corporation rejects the employers’ liability coverage. Daniel Petersen danpetersenconstruction@gmail.com Owner Polk City Polk Iowa Jim McMurray Erik Gramenz Signed
969 2024-05-02 16:15 Anonymous (not verified) 94.188.205.175 Adamantine Spine Moving 2726 Independence Rd Iowa City, IA 52240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-02 John Clifford Wallace cliff.wallace@spinemoving.com Des Moines Polk Iowa John Thomas Wallace Amanda Root Wallace Signed (1) The corporation rejects the employers’ liability coverage. Bill Hoke bill.hoke@spinemoving.com HR Des Moines Polk County Sarah Mannix Erika Banks Signed
970 2024-05-02 16:15 Anonymous (not verified) 94.188.205.167 Adamantine Spine Moving 2726 Independence Rd., Iowa City, IA 52240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-02 Emily Wallace emily.wallace@spinemoving.com Des Moines Polk Iowa Margaret Walter Dan Walter Signed (1) The corporation rejects the employers’ liability coverage. William Hoke bill.hoke@spinemoving.com Owner Iowa City Johnson Iowa Sarah Mannix Erika Banks Signed
875 2024-01-30 14:18 Anonymous (not verified) 94.188.207.226 Central Athletics LLC 7 S 4th Street Council Bluffs Iowa 51503 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-30 Cait Boyer centralathleticsia@gmail.com Council Bluffs Pottawattamie Iowa Justice Woolard Erin Eby Signed (1) The corporation rejects the employers’ liability coverage. Cait Boyer centralathleticsia@gmail.com President Council Bluffs Pottawattamie Iowa Justice Woolard Erin Eby Signed
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
950 2024-04-08 07:16 Anonymous (not verified) 94.188.207.223 J&J Exteriors 32670 190th st granger Iowa 50109 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-04-08 Joshua w klein jjexteriorsofiowa@gmail.com Granger Dallas Iowa Leah klein Ethan faughn Signed (1) The corporation rejects the employers’ liability coverage. Joshua klein jjexteriorsofiowa@gmail.com Member Granger Dallas Iowa Leah klein Ethan Faughn Signed
132 2020-11-03 13:22 Anonymous (not verified) 173.22.125.16 BeraTek Industries 407 9th Ave SE, Cedar Rapids, IA 52401 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-11-03 Ethan Davidson edavidson@beratek-industries.com Cedar Rapids Linn Iowa Raymond Gerald Beranek Ethan Paul Davidson Signed (1) The corporation rejects the employers’ liability coverage. Ethan Paul Davidson edavidson@beratek-industries.com President Cedar Rapids Linn Iowa Raymond Gerald Beranek Ethan Paul Davidson 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
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
947 2024-04-05 09:55 Anonymous (not verified) 94.188.207.228 Foley Contracting LLC 6730 Double Eagle Dr., Davenport, IA 52804 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-04-05 Samuel Nathan Foley foleycontracting@gmail.com Davenport Scott IA Gaynelle Warren Evon McNeal Signed (1) The corporation rejects the employers’ liability coverage. Samuel Foley foleycontracting@gmail.com Owner Davenport Scott IA Gaynelle Warren Evon McNeal Signed
993 2024-05-17 13:05 Anonymous (not verified) 94.188.205.176 Anacleto Campos Rojas 7 North Street Hartford, Iowa 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. 2024-05-17 Anacleto Campos Rojas anacletocampos1@icloud.com Hartford Warren Iowa Benjamin Campos Rojas Ezequiel Campos Rojas Signed (1) The corporation rejects the employers’ liability coverage. Anacleto Campos Rojas anacletocampos1@icloud.com Owner Hartford Warren Iowa Benjamin Campos Rojas Ezequiel Campos Rojas Signed
684 2023-06-13 08:54 Anonymous (not verified) 94.188.207.223 Sai Ram 123 jjj I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-01 Jane Do heather@sfmic.com Crystal Minnesota United States Jane Do Jane Signed (1) The corporation rejects the employers’ liability coverage. jkl fdaf@gmail.com fdas fdas fads fad afde fads Signed
648 2023-04-04 14:43 Anonymous (not verified) 94.188.207.224 IBARRAS CONSTRUCTION LLC 4125 56th St Des Moines IA 50310 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-04-04 SERAFIN ORENDAIN RIVERA ld.hispanicservicesllc@gmail.com Moines Polk County IA Lizeth Mora Felipe Pardo Signed (1) The corporation rejects the employers’ liability coverage. SERAFIN ORENDAIN RIVERA ld.hispanicservicesllc@gmail.com Member Moines Polk County IA Lizeth Mora Felipe Pardo Signed
888 2024-02-12 12:35 Anonymous (not verified) 94.188.205.167 Standard Builders DBA Midwest Seamless 1930 e army post rd., Des Moines IA I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-12 Andy and Axell Construction LLC bradymaher9@gmail.com Des Moines Polk IA Michael Maher Brady Maher Signed (1) The corporation rejects the employers’ liability coverage. michael maher mikemaher@midwestseamless.com Owner/President PRAIRIE CITY Jasper IA Brady Maher fernando perez Signed
982 2024-05-10 19:06 Anonymous (not verified) 94.188.207.228 Revella Salon and Spa 509 Second St Ida Grove, IA 51445 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-10 Bailey Roeder roeder428@gmail.com Ida Grove Ida Iowa Dalton Hemer Fina Roeder Signed (1) The corporation rejects the employers’ liability coverage. Bailey Roeder roeder428@gmail.com Myself Ida Grove Ida Iowa Dalton Hemer Fina Roeder Signed
393 2022-01-26 16:35 Anonymous (not verified) 216.51.137.244 Metal Works, Inc. 1015 32nd Ave W, Spencer, IA 51301 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-01 Ben Nystrom ffernandez@thamsagency.com Spencer Clay Iowa Phil Ramstack Francia Fernandez Signed (1) The corporation rejects the employers’ liability coverage. Ben Nystrom ffernandez@thamsagency.com Owner Spencer Clay Iowa Philp Ramstack Francia Fernandez Signed
134 2020-11-16 16:36 Anonymous (not verified) 192.33.191.131 Nekola Outdoors Services, Inc 722 Penrose St, Grinnell IA 50112 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-11-16 Matthew Lee Nekola NEKOLAOUTDOORSERVICES@GMAIL.COM Grinnell Poweshiek Iowa Josh Lacaeyse Frank Heinen Signed (1) The corporation rejects the employers’ liability coverage. Matthew Lee Nekola nekolaoutdoorservices@gmail.com President Grinnell Poweshiek Iowa Josh Lacaeyse Frank Heinen Signed
128 2020-10-29 07:51 Anonymous (not verified) 74.84.91.178 J & J Drywall LLC 1277 Elm 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. 2020-10-27 Jeff Frick frickdbq@gmailc.com Dubuque Dubuque IA Brenda Lewis Gabe Drewelow Signed (1) The corporation rejects the employers’ liability coverage. Jeff Frick frickdbq@gmailc.com president Dubuque Dubuque Iowa Brenda Lewis Gabe Drewelow Signed
126 2020-10-28 14:31 Anonymous (not verified) 104.207.25.44 Little Bison Daycare Center 404 2nd St. NW Buffalo Center, IA 50424 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-10-28 Cody Tyler Wirtjes cody@afschem.com Buffalo Center Winnebago Iowa Michael James Perkins Garrett Alan Asmus Signed (1) The corporation rejects the employers’ liability coverage. Cody Tyler Wirtjes cody@afschem.com Board President Buffalo Center Winnebago Iowa Michael James Perkins Garrett Alan Asmus Signed
908 2024-03-02 14:33 Anonymous (not verified) 94.188.207.230 Gerlich Enterprises 2824 Hickory Hills Ln I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-02 Paul Gerlich paul@gerlich.io Bettendorf scott IA Kelsey Gerlich Elora Gerlich Signed (1) The corporation rejects the employers’ liability coverage. Paul Gerlich paul@gelrich.io Owner Bettendorf Scott Iowa Kelsey Gerlich Garrett Gerlich Signed
909 2024-03-02 14:33 Anonymous (not verified) 94.188.207.224 Gerlich Enterprises 2824 Hickory Hills Ln I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-02 Kelsey Gerlich paul@gerlich.io Bettendorf scott IA Paul Gerlich Elora Gerlich Signed (1) The corporation rejects the employers’ liability coverage. Paul Gerlich paul@gelrich.io Owner Bettendorf Scott Iowa Elora Gerlich Garrett Gerlich Signed
910 2024-03-02 14:34 Anonymous (not verified) 94.188.207.224 Gerlich Enterprises 2824 Hickory Hills Ln I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-02 Elora Gerlich paul@gerlich.io Bettendorf scott IA Paul Gerlich Kelsey Gerlich Signed (1) The corporation rejects the employers’ liability coverage. Paul Gerlich paul@gelrich.io Owner Bettendorf Scott Iowa Kelsey Gerlich Garrett Gerlich 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
763 2023-09-05 12:31 Anonymous (not verified) 94.188.205.168 Blue Ridge Enterprises, LLC 604 old sixteen road Waterville, IA 52170 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-09-05 Nathan Eldon Leas nleas69@gmail.com Waterville Allamakee Iowa Mark Wright Gary Mahr Signed (1) The corporation rejects the employers’ liability coverage. Nathan Eldon Leas nleas69@gmail.com President/owner Waterville Allamakee Iowa Mark Wright Gary Mahr Signed
990 2024-05-15 23:19 Anonymous (not verified) 94.188.205.177 The Olam LLC 2821 S 36th Omaha Nebraska 68105 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-15 Carlos Sanchez Sjuan944@gmail.com Omaha United State Nebraska Juan Sanchez Gaspar Sanchez Signed (1) The corporation rejects the employers’ liability coverage. Carlos Sanchez theolam587@gmail.com Owner Omaha United State Nebraska Juan Sanchez Gaspar Sanchez Signed
539 2022-09-22 18:03 Anonymous (not verified) 166.181.87.86 Abarrotes La Salud, Inc. 17 North 1st Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2022-09-22 Gabriela Vargas Avalos mtownlasalud@gmail.com Marshalltown Marshall Iowa Antonio Ramirez Sanchez Genoveva Alvizu Hernandez Signed (2) The corporation declines to reject the employers’ liability coverage. Gabriela Vargas Avalos mtownlasalud@gmail.com Vice President Marshalltown Marshall Iowa Antonio Ramirez Sanchez Genoveva Alvizu Hernandez Signed
918 2024-03-11 14:29 Anonymous (not verified) 94.188.207.224 DeJear Inc. 3220 SW 34th Street, Des Moines, Iowa 50321 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-11 Marvin L. DeJear Jr marvin.dejear@gmail.com Des Moines Polk Iowa Rory Robson Geoff Matlock Signed (1) The corporation rejects the employers’ liability coverage. Marvin L. DeJear Jr dejear@dejearcorporation.com Chief Administrative Officer Des Moines Polk Iowa Rory Robson Geoff Matlock Signed
919 2024-03-11 14:32 Anonymous (not verified) 94.188.207.226 DeJear Inc. 3220 SW 34th Street, Des Moines, Iowa 50321 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-11 Deidre Olivia DeJear deidre.dejear@gmail.com Des Moines Polk Iowa Rory Robson Geoff Matlock Signed (1) The corporation rejects the employers’ liability coverage. Marvin Leo DeJear Jr dejear@dejearcorporation.com Chief Administrative Officer Des Moines Polk Iowa Rory Robson Geoff Matlock Signed
780 2023-10-04 16:18 Anonymous (not verified) 94.188.207.228 Premier Staffing Agency 6887 Dakota drive West Desmoines Iowa 50266 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-10 Felistas Kimani mwangifelistas4@gmail.com West Desmoines Dallas Iowa Denis Waweru George Komu Signed (1) The corporation rejects the employers’ liability coverage. Felistas Kimani mwangifelistas4@gmail.com member West Desmoines Dallas Iowa Denis Waweru George Komu Signed
247 2021-04-27 09:35 Anonymous (not verified) 207.191.206.210 United windows and siding 4080 1st Avenue NE, Cedar Rapids Iowa 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. (2) I decline to reject the employer’s liability coverage. 2021-04-27 Adrian Sanchez adrian@unitedwindowsandsiding.com Aurora CO United States Megan Bierley Ginger Berens Signed (2) The corporation declines to reject the employers’ liability coverage. Adrian Sanchez adrian@unitedwindowsandsiding.com Owner Aurora Jeffereson CO Megan Bierley Ginger Berens Signed
357 2021-11-10 11:32 Anonymous (not verified) 207.45.82.37 Green and Shine Services. INC 210 Ne 41st ST APT 203 Ankeny, Iowa 50021 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2021-11-10 Alex Adanel Lopez Redondo greenandshineservices@gmail.com Ankeny polk Iowa Marta Casado Giselle Roa Casado Signed (2) The corporation declines to reject the employers’ liability coverage. Alex ADANEL Lopez Redondo greenandshineservices@gmail.com owner Ankeny polk Iowa Marta Casado Giselle Roa Casado Signed
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
949 2024-04-05 20:16 Anonymous (not verified) 94.188.207.223 Viramontes Quality Lawncare LLC. 3029 E Washington Ave Des Moines,Iowa 50317 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-04-05 Andres Viramontes Barron a.viramontes1989@gmail.com Des Moines Iowa United States Clayton Garrison Gloria Cardenas Signed (1) The corporation rejects the employers’ liability coverage. Andres Viramontes a.viramontes1989@gmail.com owner Des Moines Iowa United States Clayton Garrison Gloria Cardenas Signed
58 2020-04-14 08:32 Anonymous (not verified) 174.217.17.57 Society of St Vincent de Paul, District Counsel Waterloo Iowa 320 Broadway St PO Box 2727 Waterloo IA 50704 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-14 Rodney Crowe crorod@aol.com Waterloo Blackhawk Iowa George W Karnivk Glynis R Worthington Signed (1) The corporation rejects the employers’ liability coverage. Joseph D Sobczyk joczyk@aol.com Corporate Treasurer Cdear Falls Blackhawk Iowa George W Karnick Glynis R Worthington Signed
689 2023-06-19 07:31 Anonymous (not verified) 94.188.207.228 Nenger Argueta 1317 5th Avenue Des Moines, Iowa 50314 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-19 Nenger Argueta arguetanenger30@gmail.com Des Moines Polk Iowa Gelbar Argueta Grace Argueta Signed (1) The corporation rejects the employers’ liability coverage. Nenger Argueta arguetanenger30@gmail.com Owner Des Moines Polk Iowa Gelbar Argueta Grace Argueta 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
929 2024-03-21 19:00 Anonymous (not verified) 94.188.205.167 Stewart and Belzer Construction 1103 n 8th Ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-21 Logan belzer lbelzer1999@gmail.com Washington Washington Iowa Joseph Stewart Graham Hagge Signed (1) The corporation rejects the employers’ liability coverage. Logan belzer lbelzer1999@gmail.com Owner Washington Washington Iowa Joseph Stewart Graham Hagge Signed
894 2024-02-23 08:17 Anonymous (not verified) 94.188.207.226 MIDSTATE SOLUTION LLC 107 Harrison Dr Baxter, IA 50028 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-23 Kenneth Schlosser schlosser64@icloud.com Colfax Jasper IA Kinley Bethards Grant Alexander Signed (1) The corporation rejects the employers’ liability coverage. Justin Myers justinm@midstatesolution.com Owner Baxter Jasper IA Kinley Bethards Grant Alexander Signed
335 2021-09-16 17:22 Anonymous (not verified) 64.142.5.50 Electrious Inc DBA Clean Tech 1110 Alhambra Ave Martinez CA 94533. I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-26 Robert Lemos robbie.lemos@clean.tech San Ramon Contra Costa County CA Teresa Leibnitz Greg Vermeulen Signed (1) The corporation rejects the employers’ liability coverage. Robbie Lemos robbie.lemos@clean.tech CEO San Ramon Contra Costa County CA Teresa Leibnitz Greg Vermeulen 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
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
559 2022-10-24 15:14 Anonymous (not verified) 108.178.192.251 LogicBox, Inc. 2381 Highway 169, Winterset, IA 50273 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-10-24 Jeremy Goemaat jeremy.goemaat@gmail.com Winterset Madison Iowa Janelle Goemaat Gunnar Goemaat Signed (1) The corporation rejects the employers’ liability coverage. Jeremy Goemaat jeremy.goemaat@gmail.com CEO/Owner Winterset Madison Iowa Janelle Goemaat Gunnar Goemaat Signed
274 2021-06-14 08:34 Anonymous (not verified) 207.191.207.6 Total Health Rehabilitation PC 4332 Pioneer Tr SE, Cedar Rapids, IA 52403 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-06-14 Suzanne E. Cooper tcc@acterragroup.net Cedar Rapids Linn Iowa Tad C Cooper Hallie S Cooper Signed (1) The corporation rejects the employers’ liability coverage. Suzanne E. Cooper tcc@acterragroup.net President Cedar Rapids Linn Iowa Tad C Cooper Hallie S Cooper Signed
255 2021-05-04 21:04 Anonymous (not verified) 208.38.228.16 NSENSE Incorporated 415 Stanton Ave, Suite 205, Ames, IA 50014 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-05-04 Natalia Rogovska nrogovska@n-sense.us Ames Story Iowa Petro Kyveryga Halyna Mudryk Signed (1) The corporation rejects the employers’ liability coverage. Natalia Rogovska nrogovska@n-sense.us Vice-President Ames Story Iowa Petro Kyveryga Halyna Mudryk Signed
562 2022-11-04 10:32 Anonymous (not verified) 98.159.123.124 Alli-Center 555 Cameron Way Unit 2 North Liberty Iowa 52317 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-04 Bonnie Seely bseely4@gmail.com Cedar Rapids Linn Iowa Jonah C Seely Hannah Seely Signed (1) The corporation rejects the employers’ liability coverage. Bonnie Seely bseely4@gmail.com Owner/Self Cedar Rapids Linn Iowa Jonah Seely Hannah Seely Signed
402 2022-02-09 09:46 Anonymous (not verified) 69.57.33.202 Toby K's Hideaway Inc. dba Toby K's Hideaway 1723 Mamie Eisenhower Ave, Boone IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-09 Toby Kruse samanthapeck@boehmins.com Boone Boone Iowa Samantha Peck Hans Boehm Signed (1) The corporation rejects the employers’ liability coverage. Toby Kruse samanthapeck@boehmins.com Owner Boone Boone Iowa Samantha Peck Hans Boehm Signed
936 2024-03-30 16:41 Anonymous (not verified) 94.188.205.176 Rhubarb Botanicals LLC 650 Martelle Rd, Springville IA 52336 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-30 Emma Barber emma@rhubarbbotanicals.com Springville Linn Iowa Lena Wilhelm Harvey Wilhelm Signed (1) The corporation rejects the employers’ liability coverage. Emma Barber emma@rhubarbbotanicals.com Co-Owner Springville Linn Iowa Lena Wilhelm Harvey Wilhelm 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
355 2021-11-05 15:04 Anonymous (not verified) 209.252.172.87 S&S Window Treatments Inc. 2555 Hwy 1 SW, Iowa City, IA 52240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-11-20 Joshua Yoder installation@bachmeiercarpetone.com Iowa City Johnson Iowa Heather Howell Sarah Coberley Signed (1) The corporation rejects the employers’ liability coverage. Joshua Yoder installation@bachmeiercarpetone.com Owner Iowa City Johnson Iowa Sarah Coberley Heather Howell Signed
352 2021-10-27 12:59 Anonymous (not verified) 206.80.128.65 Employee Fringes Audit Co 710 N Buxton St, Indianola, IA 50125 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-10-27 Patrick Heller patjh@yahoo.com Indianola Warren IOWA Joseph McCollum Heather Husman Signed (1) The corporation rejects the employers’ liability coverage. Judith Heller patjh@yahoo.com Owner Indianola Warren Iowa Joseph McCollum Heather Husman 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
557 2022-10-17 09:23 Anonymous (not verified) 67.22.198.94 Baker Irrigation Inc. 2621 310th St. Rock Valley, IA 51247 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-10-17 Alex DeJager alex@bakerirrigationia.com Rock Valley Sioux Iowa Jesse Niemeyer Herlan DeJager Signed (1) The corporation rejects the employers’ liability coverage. Alex DeJager alex@bakerirrigationia.com Co-Owner Rock Valley Sioux Iowa Jesse Niemeyer Herlan DeJager Signed
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
657 2023-04-20 11:33 Anonymous (not verified) 94.188.205.177 Debra Higgins 201 Cedar 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. 2023-04-20 Debra Higgins diggs0519@icloud.com Slater IA United States Howard Higgins Howard Higgins Signed (1) The corporation rejects the employers’ liability coverage. Debra Higgins diggs0519@icloud.com owner Slater IA United States Howard Higgins Howard Higgins Signed
658 2023-04-20 11:39 Anonymous (not verified) 94.188.205.167 Old Pros Consulting Inc 201 Cedar St Slater Iowa 50244 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-04-20 Debra Higgins diggs0519@icloud.com Slater IA United States Howard Higgins Howard Higgins Signed (1) The corporation rejects the employers’ liability coverage. Debra Higgins diggs0519@icloud.com owner Slater IA United States Howard Higgins Howard Higgins Signed
870 2024-01-26 07:57 Anonymous (not verified) 94.188.207.228 Kodiak Group Security LLC 1978 NW 92nd CT STE 2 Clive, Iowa 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-23 Howard Alton Johnston Jr howard@kodiakgroup.org Stuart Adair IA Joseph Crawford Howard Williams Signed (1) The corporation rejects the employers’ liability coverage. Howard Alton Johnston Jr howard@kodiakgroup.org Owner Stuart Adair Iowa Jospeh Crawford Howard Williams Signed
980 2024-05-10 14:51 Anonymous (not verified) 94.188.205.176 Access Door Automation 19068 Mynster Springs Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-10 Marshall Miller millermarshallt@outlook.com council bluffs Iowa United States Kylee Miller Ivy Miller Signed (1) The corporation rejects the employers’ liability coverage. Marshall Miller millermarshallt@outlook.com owner council bluffs Iowa United States Kylee Miller Ivy Miller Signed
907 2024-03-01 12:13 Anonymous (not verified) 94.188.207.230 Bulls Eye Builders Llc 406 E South st 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. 2024-03-01 Timothy Hansel bullseyebuildersllc@gmail.com Mechanicsville Cedar Iowa Kevin Kofron Jackie hart Signed (1) The corporation rejects the employers’ liability coverage. Timothy Hansel bullseyebuildersllc@gmail.com Owner Mechanicsville Iowa United States Kevin Kofron Jackie Hart Signed
184 2021-02-20 15:18 Anonymous (not verified) 75.162.213.162 MJM, INC. 32345 - 200TH ST., DALLAS CENTER, IA 50063 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-02-20 MICHAEL CONNOLLY MJMINC2000@AOL.COM Dallas Center Iowa United States Stephen L. Davis Jackson Plagge Signed (1) The corporation rejects the employers’ liability coverage. MICHAEL CONNOLLY MJMINC2000@AOL.COM Vice President Dallas Center Iowa United States Stephen L. Davis Jackson Plagge Signed
614 2023-02-28 07:24 Anonymous (not verified) 94.188.207.229 River City Transport, Inc 131 West 10th st, 4th floor Dubuque, IA 52001 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-02-28 Brian Brewer brian@rivercitylogistics.net Sparks NV United States Matthew Gazzola Jacob Shireman Signed (1) The corporation rejects the employers’ liability coverage. Brian Brewer brian@rivercitylogistics.net Vice President Sparks NV United States Matthew Gazzola Jacob Shireman Signed
874 2024-01-29 14:30 Anonymous (not verified) 94.188.205.174 Proefco LLC 502 s Cadwell AVE I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-30 Kendy Melendrez kendydej@gmail.com Eagle Grove IA IA Kendy Melendrez Jaime Hernandez Signed (2) The corporation declines to reject the employers’ liability coverage. Kendy Melendrez kendydej@gmail.com owner Eagle Grove IA IA Kendy Melendrez Jaime Hernandez Signed
850 2024-01-11 15:22 Anonymous (not verified) 94.188.205.167 CUB CONSTRUCTION LLC 4243 GRANDVIEW AVE, DES MOINES, IOWA 50317 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-11 SUSANA MELENDEZ melendezsusana342@gmail.com Des Moines Polk Iowa Elsa Villanueva Jaime Leiva Signed (1) The corporation rejects the employers’ liability coverage. Susana Melendez melendezsusana342@gmail.com Owner Des Moines Pok Iowa Elsa Villanueva Jaime Leiva Signed
652 2023-04-17 16:23 Anonymous (not verified) 94.188.205.177 alternative sport enterprises llc 506 6th st 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. 2023-04-17 nick carroll nick.carroll@mchsi.com Coralville IA United States Kaylyn Olson Jake Braman Signed (1) The corporation rejects the employers’ liability coverage. nick carroll nick.carroll@mchsi.com owner Coralville IA United States Kaylyn Olson Jake Braman Signed
653 2023-04-17 16:37 Anonymous (not verified) 94.188.205.166 alternative sport enterprises llc 506 6th 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. 2023-04-17 James Pearson jimpearson444@yahoo.com Savage scott MN Kaylyn Olson Jake Braman Signed (1) The corporation rejects the employers’ liability coverage. nick carroll nick.carroll@mchsi.com Owner Coralville IA United States Kaylyn Olson Jake Braman Signed
249 2021-05-03 09:29 Anonymous (not verified) 107.77.206.82 Cassatt drywall 3235 woodland dr leclaire IA I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-05-02 James Jansen james.jansen23@yahoo.com Davenport Scott IA Kara kelting Jake harris Signed (1) The corporation rejects the employers’ liability coverage. Steve cassatt cassattdrywall@gmail.com Owner Leclaire Scott IA Kara kelting Jake harris Signed
920 2024-03-18 15:42 Anonymous (not verified) 94.188.207.223 Great Tree LLC 2701 e douglas ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-18 Robert buell Greattree55@gmail.com Des Moines IA United States ryan homan Jamarlo fields Signed (1) The corporation rejects the employers’ liability coverage. Robert buell Greattree55@gmail.com company owner Des Moines IA United States ryan homan jamarlo fields Signed
921 2024-03-18 15:45 Anonymous (not verified) 94.188.207.226 Great Tree LLC 2701 e douglas ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-18 Timothy Buell treeshark52@gmail.com Des Moines IA United States ryan homan Jamarlo fields Signed (1) The corporation rejects the employers’ liability coverage. Robert buell Greattree55@gmail.com company owner Des Moines IA United States ryan homan jamarlo fields Signed
649 2023-04-07 11:56 Anonymous (not verified) 94.188.207.223 Wilcox Property Management Inc 300 N. 3rd St, Carlisle, IA 50047 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-04-07 William Wilcox bill@advancedasi.com Carlisle Polk IA Gary J Meyers James R Simmons Signed (1) The corporation rejects the employers’ liability coverage. William Wilcox bill@advancedasi.com Owner Carlisle Polk IA Gary J Meyers James R Simmons Signed
516 2022-07-19 15:43 Anonymous (not verified) 66.207.21.24 Frank Iliff 1424 B Houser Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-22 Frank Iliff rtmuscatine@gmail.com Muscatine IA United States Dewayne Hopkins James R. Bell Signed (1) The corporation rejects the employers’ liability coverage. Frank Iliff rtmuscatine@gmail.com Executive Director Muscatine IA United States Dewayne Hopkins James R. Bell Signed
517 2022-07-19 15:43 Anonymous (not verified) 66.207.21.24 Frank Iliff 1424 B Houser Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-22 Frank Iliff rtmuscatine@gmail.com Muscatine IA United States Dewayne Hopkins James R. Bell Signed (1) The corporation rejects the employers’ liability coverage. Frank Iliff rtmuscatine@gmail.com Executive Director Muscatine IA United States Dewayne Hopkins James R. Bell Signed
465 2022-05-08 19:08 Anonymous (not verified) 173.27.224.202 Vail Foundations 1508 West Clinton Ave Indianola, Iowa 50125 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-08 Cory Vail vailfoundations@gmail.com Indianola Warren Iowa Monica Vaik James Vail Signed (1) The corporation rejects the employers’ liability coverage. Cory James Vail vailfoundations@gmail.com President Indianola Warren Iowa Monica Vail James Vail Signed
576 2022-12-01 10:54 Anonymous (not verified) 97.125.244.8 R A Snow Removals, Inc 525 7th St NW, Altoona, IA 50009 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-12-01 Robert Aaron Snow snowelectric22@gmail.com Altoona Polk Iowa Shannon Keely Moses Jameson Robert Snow Signed (1) The corporation rejects the employers’ liability coverage. Robert Aaron Snow snowelectric22@gmail.com Owner Altoona Polk Iowa Shannon Keely Moses Jameson Robert Snow Signed
356 2021-11-05 20:38 Anonymous (not verified) 174.198.67.233 R.A. Snow Removals, Inc 525 7th St. NW Altoona, IA 50009 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-11-05 Robert Snow rasnowremovals.inc@gmail.com Altoona Polk Iowa Shannon Moses Jameson Snow Signed (1) The corporation rejects the employers’ liability coverage. Robert Aaron Snow rasnowremovals.inc@gmail.com President Altoona Polk Iowa Shannon Moses Jameson Snow Signed
693 2023-06-19 15:48 Anonymous (not verified) 94.188.207.224 mike mcfarland 7212 parkwood ln 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. 2023-06-19 michael chad mcfarland mikecmcfarland@gmail.com cedar rapids linn United States Omar M Zepeda jamie mcfarland Signed (1) The corporation rejects the employers’ liability coverage. michael chad mcfarland mikecmcfarland@gmail.com myself cedar rapids linn United States Omar M Zepeda jamie mcfarland Signed
340 2021-10-01 15:44 Anonymous (not verified) 3.217.29.203 Tracy Countryman 745 Robert Drive Moville, IA 51039 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-30 Tracy Countryman Tracycountryman@ymail.com Moville Woodbury Iowa Deborah Clark Jane Ashley Signed (1) The corporation rejects the employers’ liability coverage. Tracy Countryman Tracycountryman@ymail.com President Moville Woodbury Iowa Deborah Clark Jane Ashley Signed
978 2024-05-08 13:47 Anonymous (not verified) 94.188.205.174 Meridian Logistics, LLC 5249 N Park Pl NE, Unit #2060, Cedar Rapids, IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-07 Abigail Matthews almsolutions2021@gmail.com Chicago Cook IL Gayle Matteson Jane Calvert Signed (2) The corporation declines to reject the employers’ liability coverage. Abigail Matthews almsolutions2021@gmail.com Owner Chicago Cook IL Gayle Matteson Jane Calvert Signed
403 2022-02-09 14:14 Anonymous (not verified) 108.59.100.21 T Js Fencing Inc 461 Hwy 76, Harpers Ferry IA 52146 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-13 Travis Johanningmeier tjfence@acegroup.cc Harpers Ferry Allamakee Iowa Jessica Kruse Jane M Regan Signed (1) The corporation rejects the employers’ liability coverage. Travis Johanningmeier tjfence@acegroup.cc President Harpers Ferry Allamakee Iowa Jessica Kruse Jane M Regan Signed
349 2021-10-22 11:08 Anonymous (not verified) 63.152.48.235 Strong Rock and Gravel LLC 721 S Front St, Lansing, IA 52151 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-04 Ronald Strong stronggravel@gmail.com Llansing Allamakee Iowa James H Bieber Jane Tepesch Signed (1) The corporation rejects the employers’ liability coverage. James H Bieber biebinre@qwestoffice.net Insurance Agent WAUKON Allamakee Iowa James H Bieber Jane Tepesch Signed
447 2022-04-15 16:59 Anonymous (not verified) 166.181.87.86 STEVE MORRISON TRUCKING P.O. Box 66 Danville,IA 52623 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-15 Stephen D. Morrison sdmt13@gmail.com Danville Des Moines IA Ellie Miller Janice Helt Signed (1) The corporation rejects the employers’ liability coverage. Stephen Dwight Morrison sdmt13@gmail.com Owner Danville Des Moines IA Ellie Miller Janice Helt Signed
187 2021-02-25 10:44 Anonymous (not verified) 173.27.130.150 Southside Boat Club Post Office Box 674, Keokuk, Iowa 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. 2021-02-01 Michael Oney Mahoney southsideboatclub@gmail.com Keokuk Lee Iowa Roger D. Huston Janis Leann Wallingford Signed (1) The corporation rejects the employers’ liability coverage. Jeri Denise Asbridge Kerryasbridge1@mediacombb.net Treasurer Hamilton Hancock Illinois Roger D. Huston Janis Leann Wallingford Signed
189 2021-02-25 10:56 Anonymous (not verified) 173.27.130.150 Southside Boat Club Post Office Box 674, Keokuk, Iowa 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. 2021-02-01 Kathryn L. Farris southsideboatclub@gmail.com Hamilton Illinois United States Roger D. Huston Janis Leann Wallingford Signed (1) The corporation rejects the employers’ liability coverage. Jeri Denise Asbridge Kerryasbridge1@mediacombb.net Treasurer Hamilton Illinois United States Roger D. Huston Janis Leann Wallingford Signed
190 2021-02-25 10:57 Anonymous (not verified) 173.27.130.150 Southside Boat Club Post Office Box 674, Keokuk, Iowa 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. 2021-02-01 Kathryn L. Farris southsideboatclub@gmail.com Hamilton Illinois United States Roger D. Huston Janis Leann Wallingford Signed (1) The corporation rejects the employers’ liability coverage. Jeri Denise Asbridge Kerryasbridge1@mediacombb.net Treasurer Hamilton Illinois United States Roger D. Huston Janis Leann Wallingford Signed
191 2021-02-25 11:07 Anonymous (not verified) 173.27.130.150 Southside Boat Club Post Office Box 674, Keokuk, Iowa 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. 2021-02-01 Karen Colleen Rude kacee61@hotmail.com Keokuk Lee Iowa Roger D. Huston Janis Leann Wallingford Signed (1) The corporation rejects the employers’ liability coverage. Jeri Asbridge Kerryasbridge1@mediacombb.net Treasurer Hamilton Illinois United States Roger D. Huston Janis Leann Wallingford Signed
192 2021-02-25 11:10 Anonymous (not verified) 173.27.130.150 Southside Boat Club Post Office Box 674, Keokuk, Iowa 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. 2021-02-01 Jeri Asbridge kerryasbridge1@mediacombb.net Hamilton Illinois United States Roger D. Huston Janis Leann Wallingford Signed (1) The corporation rejects the employers’ liability coverage. Jeri Asbridge Kerryasbridge1@mediacombb.net Treasurer Hamilton Illinois United States Roger D. Huston Janis Leann Wallingford 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
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
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
886 2024-02-06 19:20 Anonymous (not verified) 94.188.207.227 juan carlos ruiz perez 2010 seventh st desmoines, ia 50314 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-06 juan carlos ruiz perez jruizperez898@gmail.com desmoines polk iowa guadalupe Gonzalez rojo Javier Villeda Hernandez Signed (1) The corporation rejects the employers’ liability coverage. juan c ruiz perez jruizperez898@gmail.com owner desmoines polk in guadalupe gonzalez rojo Javier Villeda Hernandez Signed
87 2020-06-09 14:49 Anonymous (not verified) 185.169.109.170 Sweeney Builders Inc 511 8th Ave NW I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-06-09 Michael Lee Sweeney mike@sweeneybuilders.com Waukon Allamakee Iowa Shawna Sweeney Jean Gavin Signed (1) The corporation rejects the employers’ liability coverage. Shawna Sweeney shawna@sweeneybuilders.com Vice President Waukon Allamakee IA Mike Sweeney Jean Gavin Signed
238 2021-04-16 08:25 Anonymous (not verified) 66.43.227.177 Zern Farm Corp 15109 330th St. Conrad, IA 50621 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-03 Jack Zern nicole.stone@gnbins.com Conrad Grundy Iowa Nicole Stone Jeff Beeghly Signed (1) The corporation rejects the employers’ liability coverage. Jack Zern nicole.stone@gnbins.com President Conrad Grundy Iowa Nicole Stone Jeff Beeghly Signed
239 2021-04-16 08:28 Anonymous (not verified) 66.43.227.177 Zern Farm Corp 15109 330th St. Conrad, IA 50621 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-03 Danice Zern nicole.stone@gnbins.com Conrad Grundy Iowa Nicole Stone Jeff Beeghly Signed (1) The corporation rejects the employers’ liability coverage. Danice Zern nicole.stone@gnbins.com Treasurer Conrad Grundy Iowa Nicole Stone Jeff Beeghly Signed
240 2021-04-16 08:30 Anonymous (not verified) 66.43.227.177 Zern Farm Corp 15109 330th St. Conrad, IA 50621 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-03 Cloris Zern nicole.stone@gnbins.com Conrad Grundy Iowa Nicole Stone Jeff Beeghly Signed (1) The corporation rejects the employers’ liability coverage. Cloris Zern nicole.stone@gnbins.com Secretary Conrad Grundy Iowa Nicole Stone Jeff Beeghly Signed
524 2022-08-08 17:13 Anonymous (not verified) 50.82.182.101 Top Dog Tile Installation 8403 Brighton Court sw Cedar Rapids, IA. 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-08-08 Philip McCurdy tiletopdog@aol.com Cedar Rapids Linn IA Joshua Walter Schumacher Jeffrey Gerard Tilkes Signed (1) The corporation rejects the employers’ liability coverage. Philip McCurdy tiletopdog@aol.com Owner Cedar Rapids Linn IA Joshua Walter Schumacher Jeff Gerard Tilkes Signed
100 2020-07-14 19:08 Anonymous (not verified) 208.90.8.234 Humboldt County Agricultural 311 N 6th Ave, P.O. Box 391, Humboldt, IA 50548 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-07-18 Jeff Haselhuhn gjhaselhuhn@gmail.com Humboldt Humboldt IA Marva Anderson Jeff Halverson Signed (1) The corporation rejects the employers’ liability coverage. Marva Anderson info@humboldtcountyfair.com Business Manager Humboldt 81 81 Marva Anderson Jeff Halverson Signed
102 2020-07-19 14:42 Anonymous (not verified) 208.90.8.234 Humboldt County Agricultural Society 311 N 6th Ave P.O. Box 391, Humboldt, IA 50548 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-07-19 Paul Davis dfs72@yahoo.com Humboldt Humboldt IA Marva Anderson Paul Davis Signed (1) The corporation rejects the employers’ liability coverage. Humboldt County Agricultural Society info@humboldtcountyfair.com Business Manager Humboldt 81 IA Marva Anderson Jeff Halverson Signed
105 2020-07-24 18:21 Anonymous (not verified) 74.115.101.23 Humboldt County Agricultural Society 311 N 6th Ave P.O. Box 391, Humboldt, IA 50548 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-07-24 Kevin Cordray kwcordray@gmail.com Humboldt Humboldt IA Marva Anderson Jeff Halverson Signed (1) The corporation rejects the employers’ liability coverage. Humboldt County Agricultural Society info@humboldtcountyfair.com Business Manager Humboldt Humboldt IA Marva Anderson Jeff Halverson Signed
75 2020-04-29 11:07 Anonymous (not verified) 107.77.206.22 ACR Construction, Inc 7330 NW 21 St. Ankeny, IA 50023 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-29 Andre Sean Drost andre.drost@acr-construction-inc.com Ankeny Polk IA Heidi Smith Jeff Smith Signed (1) The corporation rejects the employers’ liability coverage. Candace Drost acrdrost@hotmail.com President Ankeny Polk IA Heidi Smith Jeff Smith Signed
981 2024-05-10 15:31 Anonymous (not verified) 94.188.205.168 Jacob Thompson DBA Jake Thompson Trucking 2524 Delta Ave, Bridgewater, IA 50837 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-10 Jake Thompson jakethompsontrucking@yahoo.com Bridgewater Adair Iowa Daniela Scacchi Jeff Thompson Signed (1) The corporation rejects the employers’ liability coverage. Jake Thompson jakethompsontrucking@yahoo.com Self Bridgerwater Adair IA Daniela Scacchi Jeff Thompson Signed
235 2021-04-14 13:18 Anonymous (not verified) 173.31.147.225 HISTORIC ARNOLDS PARK INC 37 LAKE ST ARNOLDS PARK, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-14 LANCE EVANS joel@walkerinsuranceia.com ARNOLDS PARK DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The corporation rejects the employers’ liability coverage. JEFF VIERKANT Jeff@arnoldspark.com CEO SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JEFF VIERKANT Signed
146 2020-12-22 08:48 Anonymous (not verified) 207.155.115.120 Kafer Lawn Care 206 frentress dr Farley, IA 52046 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-22 Benjamin Terry Hayes benhayes1800@gmail.com Epworth Dubuque IA Adam Kafer Jeffery Sisler Signed (1) The corporation rejects the employers’ liability coverage. Benjamin Terry Hayes benhayes1800@gmail.com Owner Epworth Dubuque IA Adam Kafer Jeffery Sisler Signed
120 2020-10-01 09:34 Anonymous (not verified) 50.82.176.77 Kinion Towing Inc. 100 Industrial Park Drive, Clarence, IA 52216 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-30 Dale Kinion kinionas@yahoo.com Monmouth Jones Iowa Michael Blake Jeffrey Case Signed (1) The corporation rejects the employers’ liability coverage. Dale Kinion kinionas@yahoo.com President Monmouth Jones Iowa Michael Blake Jeffrey Case Signed
121 2020-10-01 09:40 Anonymous (not verified) 50.82.176.77 Kinion Towing Inc. 100 Industrial Park Drive, Clarence, IA 52216 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-30 Adam Kinion kinionas@yahoo.com Tipton Cedar Iowa Michael Blake Jeffrey Case Signed (1) The corporation rejects the employers’ liability coverage. Adam Kinion kinionas@yahoo.com Vice President Tipton Cedar Iowa Michael Blake Jeffrey Case Signed
585 2022-12-15 20:32 Anonymous (not verified) 192.110.196.132 Maywood Enterprises, Inc. 28345 Highway 52, Bellevue, IA 52031 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-12-15 Ann L Wachtel annw@financepro123.com Bellevue Jackson Iowa Katie Laban Jeffrey Laban Signed (1) The corporation rejects the employers’ liability coverage. Ann L Wachtel annw@financepro123.com President Bellevue Jackson IA Katie Laban Jeffrey Laban Signed
135 2020-11-20 11:05 Anonymous (not verified) 208.95.1.97 Burds Communities Inc. 606 S 3rd Street, Bellevue, IA 52031 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-11-20 Todd Burds burdshousing@yahoo.com Peosta Dubuque IA Paula Fitzgerald Jena Wilwert Signed (1) The corporation rejects the employers’ liability coverage. Todd Burds burdshousing@yahoo.com President Peosta Dubuque IA Paula Fitzgerald Jena Wilwert Signed
136 2020-11-20 11:06 Anonymous (not verified) 208.95.1.97 Burds Communities Inc. 606 S 3rd Street, Bellevue, IA 52031 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-11-20 Tim Burds burdshousing@yahoo.com Peosta Dubuque IA Paula Fitzgerald Jena Wilwert Signed (1) The corporation rejects the employers’ liability coverage. Tim Burds burdshousing@yahoo.com Vice President Peosta Dubuque IA Paula Fitzgerald Jena Wilwert 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
534 2022-09-09 08:35 Anonymous (not verified) 192.95.125.128 Darri, Inc. 903 W 4th Street, Vinton, IA 52349 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-09 Teri Jo Sellers teri@bobbinsandboards.com Vinton Benton Iowa Hanna Gregory Jennie Lynn Roster Signed (1) The corporation rejects the employers’ liability coverage. Darran Kenneth Sellers darran.sellers@mrhandyman.com President Vinton Benton Iowa Hanna Gregory Jennie Lynn Roster Signed
666 2023-05-05 16:20 Anonymous (not verified) 94.188.205.177 Furever Friends Rescue of Appanoose, Inc PO Box 663, 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. 2023-05-05 Michael Miller mrmillerfb@gmail.com Centerville Appanoose Iowa Kimberly Stonehouse Jennifer Appler Signed (1) The corporation rejects the employers’ liability coverage. Michael Miller mrmillerfb@gmail.com Secretary Centerville Appanoose Iowa Kimberly Stonehouse Jennifer Appler 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
526 2022-08-17 11:16 Anonymous (not verified) 173.27.233.86 Bradens Roofing and Construction Llc 2450 Hart Avenue I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-08-17 Arsenio Vargas Velazquez avargas409@gmail.com Des Moines polk Iowa Julissa Dionicio Jennifer Dionicio Signed (1) The corporation rejects the employers’ liability coverage. Arsenio Vargas Velazquez avargas409@gmail.com owner Des Moines Polk Iowa Julissa Dionicio Jennifer Dionicio Signed
771 2023-09-17 13:33 Anonymous (not verified) 94.188.205.176 Apex Landlord Services LLC 429 Shetland Dr 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. 2023-09-17 Benjamin Walhood info@apexlandlordservices.com Cedar Rapids Linn Iowa Justin Goebel Jennifer Goebel Signed (1) The corporation rejects the employers’ liability coverage. Benjamin Walhood info@apexlandlordservices.com Managing Member Cedar Rapids Linn Iowa Justin Goebel Jennifer Goebel Signed
60 2020-04-20 13:06 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, PO Box 609, Arnolds Park, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 Charley Whittenburg jennifer@walkerinsuranceia.com Spencer Clay Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Charley Whittenburg jennifer@walkerinsuranceia.com Vice President Spencer Clay Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
61 2020-04-20 13:13 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 Bruce Tamisiea jennifer@walkerinsuranceia.com Wahpeton Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Bruce Tamisiea jennifer@walkerinsuranceia.com Board Member Wahpeton Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
62 2020-04-20 13:18 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 Ron Morocco jennifer@walkerinsuranceia.com Milford Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Ron Morocco jennifer@walkerinsuranceia.com Board Member Milford Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
63 2020-04-20 13:23 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 Suzie Wilmot jennifer@walkerinsuranceia.com Minneapolis Hennepin Minnesota Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Suzie Wilmot jennifer@walkerinsuranceia.com Board Member Minneapolis Hennepin Minnesota Joseph Thomas Loring Jennifer Janet Youngwirth Signed
64 2020-04-20 13:30 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 Mike Bennett jennifer@walkerinsuranceia.com Jefferson Union South Dakota Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Mike Bennett jennifer@walkerinsuranceia.com Treasurer Jefferson Union South Dakota Joseph Thomas Loring Jennifer Janet Youngwirth Signed
65 2020-04-20 13:37 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 Denny Walker jennifer@walkerinsuranceia.com West Okoboji Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Denny Walker jennifer@walkerinsuranceia.com Board Member West Okoboji Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
66 2020-04-20 13:41 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 Tresa Hussong jennifer@walkerinsuranceia.com Arnolds Park Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Tresa Hussong jennifer@walkerinsuranceia.com Board Member Arnolds Park Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
67 2020-04-20 13:46 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 John Franken jennifer@walkerinsuranceia.com Spirit Lake Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. John Franken jennifer@walkerinsuranceia.com Vice President Spirit Lake Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
68 2020-04-20 13:50 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 Jill Harms jennifer@walkerinsuranceia.com Milford Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Jill Harms jennifer@walkerinsuranceia.com President Milford Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
70 2020-04-21 10:29 Anonymous (not verified) 173.24.181.211 Mr. Drain Man LLC 607 36th Street, Spirit Lake IA 51360 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-21 Jan Coon jennifer@walkerinsuranceia.com Spirit Lake Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Mr Drain Man LLC jennifer@walkerinsuranceia.com Member Spirit Lake Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
248 2021-04-29 09:59 Anonymous (not verified) 173.31.147.225 BOJI CUSTOM METAL WORKS INC 402 E 4TH ST SPENCER, IA 51301 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-23 SCOTT PYLE scottpyle98@hotmail.com FOSTORIA CLAY IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The corporation rejects the employers’ liability coverage. SCOTT PYLE joel@walkerinsuranceia.com PRESIDENT FOSTORIA CLAY IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
323 2021-08-30 12:22 Anonymous (not verified) 173.19.179.111 OKOBOJI TREE SPECIALISTS II iNC PO BOX 515 MILFORD, IA 51351 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-13 THOMAS WRIGHT joel@walkerinsuranceia.com MILFORD DICKINSON IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The corporation rejects the employers’ liability coverage. THOMAS WRIGHT joel@walkerinsuranceia.com ADMIN ST PAUL MN 55106 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
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
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
81 2020-05-11 16:10 Anonymous (not verified) 97.125.253.184 Rundle Creations L.L.C. 5816 Urbandale Avenue, Des Moines, IA 50322 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-05-11 Mark Lavern Rundle II rundlecreations@gmail.com Des Moines Polk Iowa Luis Alex Jimenez Jennifer Lea Griffith Signed (1) The corporation rejects the employers’ liability coverage. Erika Anne Rundle rundlecreations@gmail.com Owner Des Moines Polk Iowa Luis Alex Jimenez Jennifer Lea Griffith Signed
202 2021-03-08 10:43 Anonymous (not verified) 151.147.196.21 Iowa Gold Distributing, Inc. 600 Iehl Street, Central City, IA 52214 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-02-10 Rebeccah Walters igdenv@aol.com Central City Linn Iowa William Walters Jennifer Leinen Signed (1) The corporation rejects the employers’ liability coverage. Rebeccah Walters igdenv@aol.com Secretary Central City Linn Iowa William Walters Jennifer Leinen Signed
204 2021-03-08 10:43 Anonymous (not verified) 151.147.196.21 Iowa Gold Distributing, Inc. 600 Iehl Street, Central City, IA 52214 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2021-02-10 Brad Coates igdenv@aol.com Central City Linn Iowa William Walters Jennifer Leinen Signed (2) The corporation declines to reject the employers’ liability coverage. Brad Coates igdenv@aol.com Director Central City Linn Iowa William Walters Jennifer Leinen Signed
154 2021-01-06 13:23 Anonymous (not verified) 167.142.147.6 PACIFIC DRYWALL CORPORATION 105 SNYDER DRIVE HUXLEY, IOWA 50124 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2021-01-06 LUIS MANUEL AVALOS CASTELANOS PACIFICDRYWALLCORP@GMAIL.COM DES MOINES POLK IOWA JENNIFER LYNNE ESCOBAR JUAN JOSE AVALOS CASTELLANOS Signed (2) The corporation declines to reject the employers’ liability coverage. LUIS MANUEL AVALOS CASTELANOS PACIFICDRYWALLCORP@GMAIL.COM PRESIDENT DES MOINES POLK IOWA JUAN JOSE AVALOS CASTELLANOS JENNIFER LYNNE ESCOBAR Signed
655 2023-04-18 16:59 Anonymous (not verified) 94.188.205.166 Next level tile and marble 6918 NW 4th st Ankeny 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. 2023-04-18 Jason John Henry Schneider jjhschneider@gmail.com Ankeny Polk Iowa Mario Demarco Jennifer Schneider Signed (1) The corporation rejects the employers’ liability coverage. Jason Schneider jjhschneider@gmail.com Owner Ankeny Polk Iowa Mario Demarco Jennifer Schneider Signed
579 2022-12-07 14:37 Anonymous (not verified) 96.31.1.206 IGL RENTAL LLC PO BOX 317 ARNOLDS PARK IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-10-25 CHAD JONES STAYBOJI@GMAIL.COM ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The corporation rejects the employers’ liability coverage. CHAD JONES STAYBOJI@GMAIL.COM MEMBER ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
861 2024-01-19 11:52 Anonymous (not verified) 94.188.207.228 Nex level moving llc 5634 Deerwood ST SW, Cedar Rapids, IA 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-19 Martavian mborseth0110@gmail.com Cedar rapids Linn Iowa Christine B. Jenny B. Signed (1) The corporation rejects the employers’ liability coverage. Martavian Borseth mborseth0110@gmail.com Self Cedar Rapids Linn Iowa Christine B. Jenny B. Signed
760 2023-09-01 08:43 Anonymous (not verified) 94.188.207.226 Paradigm Group, LLC 3263 Cumming Road, Cumming, IA 50061 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-09-01 Conor Davis conor@cdavisflooring.com Urbandale Dallas Iowa Jered Holker Wes Duncan Signed (1) The corporation rejects the employers’ liability coverage. Ryan Shabino ryan@prdgmgroup.com Owner Cumming Madison Iowa Wes Duncan Jered Holker Signed
761 2023-09-01 08:52 Anonymous (not verified) 94.188.205.177 Paradigm Group, LLC 3263 Cumming Road, Cumming, IA 50061 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-09-01 Rony De Leon ronydeleon22@icloud.com Des Moines Polk Iowa Jered Holker Wes Duncan Signed (1) The corporation rejects the employers’ liability coverage. Ryan Shabino ryan@prdgmgroup.com Owner Cumming Madison Iowa Wes Duncan Jered Holker Signed
762 2023-09-01 09:00 Anonymous (not verified) 94.188.207.226 Paradigm Group, LLC 3263 Cumming Road, Cumming, IA 50061 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-09-01 Hunter Fees iowatuckpointing@gmail.com Carlisle Warren Iowa Jered Holker Wes Duncan Signed (1) The corporation rejects the employers’ liability coverage. Ryan Shabino ryan@prdgmgroup.com Owner Cumming Madison Iowa Wes Duncan Jered Holker Signed
563 2022-11-09 10:28 Anonymous (not verified) 199.168.243.195 Mensingers Aquatic Resources, Inc. 2119 Oak Trail Drive I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-09 Jeff Mensinger jeffrey.mensinger@hdrinc.com Camanche ia United States Cody Mensinger Jeremiah Haas Signed (1) The corporation rejects the employers’ liability coverage. Jeff Mensinger jeffrey.mensinger@hdrinc.com President Camanche ia United States Cody Mensinger Jeremiah Haas Signed
620 2023-03-06 09:26 Anonymous (not verified) 94.188.207.225 Monhec industrial construction llc 616 sw 62 nd st desmoines iowa 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. 2023-03-06 Hector Montoya halexisjr@hotmail.com Desmoines Polk Iowa Adriana rojo Jeremy boeck Signed (1) The corporation rejects the employers’ liability coverage. Hector Montoya halexisjr@hotmail.com Owner Desmoines Polk Iowa Adriana rojo Jeremy boeck Signed
676 2023-05-26 16:16 Anonymous (not verified) 94.188.207.230 Miller Lawn Care LLC 1323 S Hwy 52 Guttenberg IA 52052 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-26 Steven Miller nicole@cioia.com Guttenberg Clayton IA Nicole Parker Jerry J Rochford Signed (1) The corporation rejects the employers’ liability coverage. Steven Miller nicole@cioia.com owner-self Guttenberg Clayton IA Nicole Parker Jerry J Rochford Signed
540 2022-09-22 18:48 Anonymous (not verified) 172.58.84.145 José j Castañeda lara 1722 22st Des Moines iowa 50310 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-22 José j Castañeda lara jesuscastaneda28@gmail.com Des Moines Polk Iowa Joseph Powell Jesica Powell Signed (1) The corporation rejects the employers’ liability coverage. José j Castañeda lara jesuscastaneda28@gmail.com Self Des Moines Polk Iowa Joseph Powell Jesica Powell Signed
241 2021-04-16 09:14 Anonymous (not verified) 75.89.76.245 PIllar Inc 906 W 18th Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-16 Jordan Watkins jordan@pillariowa.com Altoona IA United States Beth May jesse backstrom Signed (1) The corporation rejects the employers’ liability coverage. Matt Klucas matt@pillariowa.com VP Ft Dodge Webster Iowa Beth May Jesse Backstrom Signed
461 2022-05-02 11:08 Anonymous (not verified) 192.119.212.86 Iceberg Enterprises LLC 101 E. 1st street Arthur IA 51431 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-02 Jesse Bergman jk_montana@yahoo.com arthur Iowa United States Maren Smith Darren Smith Signed (1) The corporation rejects the employers’ liability coverage. Katherine Bergman jk_montana@yahoo.com Owner Arthur IOWA United States Susan Bergman Jesse Bergman Signed
586 2022-12-16 15:53 Anonymous (not verified) 184.184.197.146 Halide Biologics 330 Golfview Ave, Iowa City IA 52246 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-12-15 Daniel Infield danielinfield@gmil.com Bennington Douglas Nebraska Alexander Estell Jesse Herrera Signed (1) The corporation rejects the employers’ liability coverage. Daniel Infield danielinfield@gmail.com President Bennington NE United States Alexander Estell Jesse Herrera Signed
542 2022-09-26 19:26 Anonymous (not verified) 45.78.142.139 Doyle Vondrak Trucking 315 Vermont Avenue, Kingsley, Iowa 51028 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-26 Doyle P Vondrak dpvondrak@wiatel.net Kingsley Plymouth Iowa Jayne R Vondrak Jesse M Vondrak Signed (1) The corporation rejects the employers’ liability coverage. Doyle P Vondrak dpvondrak@wiatel.net self-employed; single employee Kingsley Plymouth Iowa Jayne R Vondrak Jesse M Vondrak Signed
32 2020-01-14 10:33 Anonymous (not verified) 108.171.132.189 B & C Lawn Care Inc P.O. Box 55, Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-01-01 Travis Garrett onethird4599@gmail.com Boone Boone Iowa Katie Frame Jessica Carroll Signed (1) The corporation rejects the employers’ liability coverage. Travis Garrett onethird4599@gmail.com Owner Boone Boone IOWA Katie Frame Jessica Carroll Signed
34 2020-01-16 13:10 Anonymous (not verified) 108.171.132.188 B & C Lawn Care Inc P.O. Box 55, Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-01-01 Caleb Elliott onethird4599@gmail.com Boone Boone Iowa Katie Frame Jessica Carroll Signed (1) The corporation rejects the employers’ liability coverage. Caleb Elliott onethird4599@gmail.com Owner Boone Boone IOWA Katie Frame Jessica Carroll Signed
71 2020-04-27 16:23 Anonymous (not verified) 140.82.166.162 Loss Control Specialist Inc 1409 Jackson Woods Ct NW Cedar Rapids, IA 52409 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-02-28 James Riggert jim@losscontrolspecialist.com Cedar Rapids Linn Iowa Megan Thomas Jessica Droppert Signed (1) The corporation rejects the employers’ liability coverage. James Riggert jim@losscontrolspecialist.com President Cedar Rapids Linn Iowa Megan Thomas Jessica Droppert Signed
72 2020-04-27 16:24 Anonymous (not verified) 140.82.166.162 Loss Control Specialist Inc 1409 Jackson Woods Ct NW Cedar Rapids, IA 52409 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-02-28 Pamala Riggert jim@losscontrolspecialist.com Cedar Rapids Linn Iowa Megan Thomas Jessica Droppert Signed (1) The corporation rejects the employers’ liability coverage. Pamala Riggert jim@losscontrolspecialist.com Secretary Cedar Rapids Linn Iowa Megan Thomas Jessica Droppert Signed
53 2020-03-30 11:09 Anonymous (not verified) 45.42.5.219 Taylor's Tri-State Construction 660 Tanzanite Drive, Dubuque, IA 52001 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-03-06 John Taylor taylorsconstruction78@yahoo.com Dubuque Dubuque Iowa Brenda Lewis Jessica Stepp Signed (1) The corporation rejects the employers’ liability coverage. John Taylor taylorsconstruction78@yahoo.com Co-owners Dubuque Dubuque Iowa Brenda Lewis Jessica Stepp Signed
171 2021-01-26 15:07 Anonymous (not verified) 174.198.73.28 R. A. Snow Removals, Inc 525 7th St. NW I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-26 Robert Aaron Snow rasnowremovals.inc@gmail.com Altoona Polk Iowa Shannon Keely Moses Jessy James Dentler Signed (1) The corporation rejects the employers’ liability coverage. Robert Aaron Snow rasnowremovals.inc@gmail.com President Altoona Polk Iowa Shannon Keely Moses Jessy James Dentler Signed
785 2023-10-10 15:42 Anonymous (not verified) 94.188.207.228 KO pest solutions LLC 1208 s zenith ave davenport 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. 2023-10-10 Jesus Correa Jr k.o.pestcontrol@outlook.com davenport Scott Iowa Jesus Correa Jr Jesus Correa Jr Signed (1) The corporation rejects the employers’ liability coverage. Jesus correa Jr k.o.pestcontrol@outlook.com owner Davenport Scott iowa Jesus correa Jesus Correa Signed
508 2022-07-04 18:49 Anonymous (not verified) 107.77.210.228 RM Construction, Rafael Marquez DBA 6520 SE 5th ST, Apt 4, Des Moines, IA 50315 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-04 Rafael Marquez marquezrafael1@outlook.com 6520 SE 5th ST, Apt 4, Des Moines IA, 50315 Polk IOWA Richard Yanez Jesus Perez Signed (1) The corporation rejects the employers’ liability coverage. Rafael Marquez marquezrafael1@outlook.com owner Des Moines Polk IOWA Richard Yanez Jesus Perez Signed
139 2020-11-24 15:45 Anonymous (not verified) 174.219.2.33 Dan Petersen Construction LLC 1725 South 14th St, Polk City, IA 50226 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2019-11-24 Daniel Petersen danpetersenconstruction@gmail.com Polk City Polk Iowa Erik Gramenz Jim McMurray Signed (1) The corporation rejects the employers’ liability coverage. Daniel Petersen danpetersenconstruction@gmail.com Owner Polk City Polk Iowa Erik Gramenz Jim McMurray Signed
757 2023-08-28 12:11 Anonymous (not verified) 94.188.207.230 J.R. Stelzer Co 5850 Russell Dr. Lincoln, NE 68507 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-28 Mike Stelzer mike@jrstelzer.com Lincoln NE United States Bill Stelzer Jim Stelzer Signed (1) The corporation rejects the employers’ liability coverage. Mike Stelzer mike@jrstelzer.com President Lincoln Lancaster NE Bill Stelzer Jim Stelzer Signed
329 2021-09-08 10:18 Anonymous (not verified) 206.80.128.71 H F Corporation 105 E Oskaloosa Pella, IA 50219 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-08 Bharat Patel super8pella@gmail.com Pella Marion Iowa Mark Chambers Jim Wessels Signed (1) The corporation rejects the employers’ liability coverage. Jeremy Rogstad jeremy@jeremyrogstad.com State Farm Agent Iowa Floyd Iowa Mark Chambers Jim Wessels Signed
330 2021-09-08 10:20 Anonymous (not verified) 206.80.128.71 H F Corporation 105 Oskaloosa St Pella, IA 50219 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-08 Nayan Patel super8pella@gmail.com Pella Marion Iowa Mark Chambers Jim Wessels Signed (1) The corporation rejects the employers’ liability coverage. Jeremy Rogstad jeremy@jeremyrogstad.com State Farm Agent Charles City Floyd Iowa Mark Chambers Jim Wessels Signed
331 2021-09-08 10:21 Anonymous (not verified) 206.80.128.71 H F Corporation 105 Oskaloosa St Pella, IA 50219 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-08 Dinesh Patel super8pella@gmail.com Pella Marion Iowa Mark Chambers Jim Wessels Signed (1) The corporation rejects the employers’ liability coverage. Jeremy Rogstad jeremy@jeremyrogstad.com State Farm Agent Charles City Floyd Iowa Mark Chambers Jim Wessels Signed
938 2024-04-01 07:12 Anonymous (not verified) 94.188.207.225 Martinez HVAC Construction LLC 512 Anderson st jewell IA 50130 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-04-01 Felipe Martinez miguelrmartinez26@gmail.com Jewell Hamilton IA Brady Cooper Job Cooper Signed (1) The corporation rejects the employers’ liability coverage. Felipe Martinez miguelrmartinez26@gmail.com owner Jewell Hamilton IA Brady Cooper Job Cooper Signed
897 2024-02-24 18:40 Anonymous (not verified) 94.188.205.169 Rays Plumbing Heating & Air conditioning LLC. 305 Cedar St. Tipton Iowa 52772 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-02-24 Raymond Zaruba raymondzaruba@gmail.com TIPTON IA United States Kevin Kofron Jodi Kofron Signed (1) The corporation rejects the employers’ liability coverage. Raymond Zaruba raymondzaruba@gmail.com Owner Tipton Iowa 52772 Cedar Iowa Kevin Kofron Jodi Kofron Signed
44 2020-03-09 10:51 Anonymous (not verified) 184.63.116.185 STURCO BUILDERS 24472 15TH AVE NEW VIRGINIA IA 50210 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-03-09 LANE WILLIAM STURTZ Sturcobuilders@live.com New virginia warren Iowa EMILY LAURA STURTZ JODI LEEANN GARNER Signed (1) The corporation rejects the employers’ liability coverage. LANE WILLIAM STURTZ Sturcobuilders@live.com OWNER NEW VIRGINIA WARREN IOWA EMILY LAURA STURTZ JODI LEEANN GARNER Signed
914 2024-03-08 09:02 Anonymous (not verified) 94.188.205.167 Lubbock Construction Inc 3035 66 St Shellsburg IA 52332 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-08 Justin L Lubbock justinlubbock@yahoo.com Shellsburg Benton IA Cherie Lynn Scott Jodie Marie Little Signed (1) The corporation rejects the employers’ liability coverage. Justin L Lubbock justinlubbock@yahoo.com President Shellsburg Benton IA Cherie Lynn Scott Jodie Marie Little Signed
312 2021-08-18 22:29 Anonymous (not verified) 166.181.81.19 Basset Express Inc. 1572 Underwood 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. 2021-08-18 Jay R Chelf bassetexpress@yahoo.com Muscatine Muscatine IA Bill Petersen Jody L Young Signed (1) The corporation rejects the employers’ liability coverage. Patricia Ann Chelf bassetexpress@gmail.com President Muscatine Muscatine Iowa Bill Petersen Jody L Young Signed
475 2022-05-19 10:11 Anonymous (not verified) 172.86.13.54 BOLT HOLDINGS Inc. and Holt Precision dba Holt Bladeworks and Holt Kinetic Solutions 3230 N. Center Point Rd Unit 204, Marion, IA 52302 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-19 Angey Holt Angey@Holtkineticsolutions.com Robins Linn Iowa Lisa Gleason Danielle Congleton Signed (1) The corporation rejects the employers’ liability coverage. Lisa Gleason Lisa@holtkineticsolutions.com General Manager Marion Linn Iowa Danielle Congleton Joe Holt Signed
272 2021-06-08 12:32 Anonymous (not verified) 40.135.3.146 Gordinier Construction Inc 9555 SE 6th Ave, Runnells IA 50237 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-06 Tim Gordinier gordinierconstruction@gmail.com Runnnells POLK IA Robert Simmons Joe Meyers Signed (1) The corporation rejects the employers’ liability coverage. Tim Gordinier gordinierconstruction@gmail.com Self Runnells Polk IA Robert Simmons Joe Meyers Signed
273 2021-06-08 12:34 Anonymous (not verified) 40.135.3.146 Gordinier Construction Inc 9555 SE 6th Ave, Runnells IA 50237 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-06 Dustin Gordinier gordinierconstruction@gmail.com Runnells Polk IA Robert Simmons Joe Meyers Signed (1) The corporation rejects the employers’ liability coverage. Dustin Gordinier gordinierconstruction@gmail.com Self Runnells 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
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
327 2021-09-07 08:58 Anonymous (not verified) 173.28.32.129 Sas Entertainment, Inc. PO Box 47 LeClaire, IA 52753 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-07 Randy Saskowski sales@sasdjs.com Geneseo henry illinois Dan Terry Joe Roberts Signed (1) The corporation rejects the employers’ liability coverage. randy Saskowski sales@sasdjs.com President Geneseo henry illinois Dan Terry Joe Roberts Signed
286 2021-07-10 13:16 Anonymous (not verified) 69.57.205.10 Marquis Aviation, Inc 845 E. Redwood Cir. I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-07-10 Robert Wescott Cantrell rcr4@comcast.net Hanford Kings CA Shirley J. Loney Joel L. Meyer Signed (1) The corporation rejects the employers’ liability coverage. Robert W. Cantrell rcr4@comcast.net Secretary Hanford Kings CA Shirley J. Loney Joel L. Meyer Signed
520 2022-07-23 14:19 Anonymous (not verified) 69.57.205.10 Marquis Aviation, Inc 845 E. Redwood Circle I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-23 Robert Wescott Cantrell marquisaviationinc@yahoo.com Hanford Kings CA Shirley J. Loney Joel L. Meyer Signed (1) The corporation rejects the employers’ liability coverage. Robert W. Cantrell marquisaviationinc@yahoo.com Secretary Hanford Kings CA Shirley J. Loney Joel L. Meyer Signed
642 2023-03-30 09:56 Anonymous (not verified) 94.188.205.174 Adamantine Spine Moving 2726 Independence Road Iowa City, Iowa 52240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-30 John Clifford Wallace cliff.wallace@spinemoving.com Des Moines Polk IA Taylor Christian Roth Ashley Anne Koch Signed (1) The corporation rejects the employers’ liability coverage. Ashley Anne Koch ashley.koch@spinemoving.com HR, Safety and Compliance Manager Des Moines Polk Iowa Taylor Christian Roth John Clifford Wallace Signed
173 2021-01-26 19:29 Anonymous (not verified) 173.17.84.174 Robert Schroeder const. inc 10984 150 th. st. davenport ia. 52804 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-26 ROBERT SCHROEDER r.schroeder@aol.com davenport scott ia. Debra Blaser John Ekin Signed (1) The corporation rejects the employers’ liability coverage. ROBERT SCHROEDER r.schroeder@aol.com President davenport scott ia. Debra Blaser John Ekin Signed
236 2021-04-14 14:59 Anonymous (not verified) 75.89.76.245 Pillar Inc 906 W 18th St. Nevada, IA 50201 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-14 Jason J Burke jason@pillariowa.com Huxley IA United States Debbie Goetz John Goetz Signed (1) The corporation rejects the employers’ liability coverage. Matt Klucas matt@pillariowa.com VP Fort Dodge IA United States Debbie Goetz John Goetz Signed
147 2020-12-29 13:57 Anonymous (not verified) 208.38.231.99 CJ Construction 2129N Zenith 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. 2020-12-29 Christine Ekin John Ekin chrohn2009@yahoo.com Davenport Iowa United States Christine Ekin John J Ekin Signed (1) The corporation rejects the employers’ liability coverage. CJ Construction chrohn2009@yahoo.com Co Owner Davenport Iowa United States Christine Ekin John J Ekin Signed
651 2023-04-10 13:21 Anonymous (not verified) 94.188.205.175 Deep Cleaning Janitorial Inc 3131 33rd Ave SW Ceder 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. 2023-04-10 Ray Robertson deepcleaning0142@gmail.com Cedar Rapids IA United States Shelley Robertson William Robertson Signed (1) The corporation rejects the employers’ liability coverage. Paul Mwai deepcleaning0142@gmail.com Co-Owner Cedar Rapids Linn United States Mary Ngotho John Johnson Signed
872 2024-01-26 10:28 Anonymous (not verified) 94.188.205.177 Sole proprietor- Dennis R. Oliver dba Olivers Oasis Communications 150 Spring Valley Ct. Springtown, TX 76082 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-26 Dennis Reeves Oliver doliversoasis@aol.com Springtown Parker Texas Helen Frances Steil John Kevin Steil Signed (1) The corporation rejects the employers’ liability coverage. Dennis Reeves Oliver doliversoasis@aol.com Self Springtown Parker TX Helen Frances Steil John Kevin Steil Signed
397 2022-02-01 10:30 Anonymous (not verified) 159.242.43.24 Providence Casework PO Box 205 Rockwell, IA 50469 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-01 Neal Keeling office@procaseworks.com Rockwell Cerro Gordo Iowa Josh Olson John Moran Signed (1) The corporation rejects the employers’ liability coverage. Neal Keeling office@procaseworks.com Owner Rockwell Cerro Gordo Iowa Josh Olson John Moran Signed
321 2021-08-27 16:10 Anonymous (not verified) 173.30.51.29 Diamond Bath LLC 3184 Berkshire PKwy Clive, Iowa 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-02 Patricia Fisk diamondbathllc@gmail.com Clive Iowa United States Joshua A Fisk John S Lanscak III Signed (1) The corporation rejects the employers’ liability coverage. Patricia Fisk diamondbathllc@gmail.com Owner/CEO Clive Iowa United States Joshua A Fisk John S Lanscak III Signed
884 2024-02-05 11:31 Anonymous (not verified) 94.188.205.175 NeX Level Moving LLC 5634 Deerwood ST SW cedar rapids iowa 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-05 Robert Sanders Sandersrob101300@gmail.com Cedar Rapids Linn Iowa dallas haul johntay buck Signed (1) The corporation rejects the employers’ liability coverage. Robert Sanders Sandersrob101300@gmail.com self cedar rapids linn iowa dallas haul Johntay buck Signed
268 2021-05-25 10:03 Anonymous (not verified) 174.198.97.100 Paradigm Construction, LLC 960 Pelican Dr I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-05-25 Joshua Beougher jbooyah84@gmail.com Winterset Madison Iowa Ryan Shabino Jonathon Curtis Signed (1) The corporation rejects the employers’ liability coverage. Ryan Shabino ryan@prdgmconstruction.com Owner Polk City Polk Iowa Josh Beougher Jonathon Curtis Signed
468 2022-05-12 11:33 Anonymous (not verified) 173.23.25.243 RS Remodelers 2863 104th St Urbandale IA 50322 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2022-05-12 Robert Nevitt rwnevitt@yahoo.com PERRY DALLAS IA Steve Dillon Jordan Nevitt Signed (2) The corporation declines to reject the employers’ liability coverage. Robert Nevitt clearchoicedesmoinesia@gmail.com Owner Urbandale Dallas ia Steve Dillon Jordan Nevitt Signed
469 2022-05-12 11:38 Anonymous (not verified) 173.23.25.243 RS- Remodelers 2863 104th St Urbandale IA 50322 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2022-05-12 Stephen Dillon clearchoicedesmoinesia@gmail.com Waukee Dallas IA Rob Nevitt Jordan Nevitt Signed (2) The corporation declines to reject the employers’ liability coverage. Stephen clearchoicedesmoinesia@gmail.com Owner Waukee Dallas IA Rob Nevitt Jordan Nevitt Signed
473 2022-05-16 14:20 Anonymous (not verified) 167.142.231.34 Trust Builders, LLC 1055 Jordan Creek Parkway, Suite 200, West Des Moines, IA 50226 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-16 Christopher Dean Petersen chrispetersen@trustbuildersiowa.com Polk City Polk Iowa Curtis William Blake Joseph Duane Meints Signed (1) The corporation rejects the employers’ liability coverage. Christopher Dean Petersen chrispetersen@trustbuildersiowa.com Owner Polk City Polk Iowa Curtis William Blake Joseph Duane Meints Signed
41 2020-02-16 19:09 Anonymous (not verified) 207.199.193.217 S J Hernandez, Inc 19738 133rd Street Bloomfield, IA 52537 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-02-16 Jessica Hernandez jessieatcjs@gmail.com Bloomfield Davis Iowa Salvador Hernandez-Perez Joseph Olinger Signed (1) The corporation rejects the employers’ liability coverage. Jessica Hernandez jessieatcjs@gmail.com Owner Bloomfield Davis Iowa Salvador Hernandez-Perez Joseph Olinger Signed
42 2020-02-16 19:13 Anonymous (not verified) 207.199.193.217 S J Hernandez, Inc 19738 133rd Street Bloomfield, IA 52537 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-02-16 Salvador Hernandez-Perez jessieatcjs@gmail.com Bloomfield Davis Iowa Jessica Hernandez Joseph Olinger Signed (1) The corporation rejects the employers’ liability coverage. Salvador Hernandez-Perez jessieatcjs@gmail.com Owner Bloomfield Davis Iowa Jessica Hernandez Joseph Olinger Signed
499 2022-06-22 03:40 Anonymous (not verified) 64.251.168.116 VALBURG AERIAL SPRAYING INC. 27656 SD Hwy 44 WHITE RIVER SD 57579 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-19 Dan A Valburg agflyer620@gwtc.net White River SD SD LANDON HOSSLE JOSH HICKS Signed (1) The corporation rejects the employers’ liability coverage. Dan A Valburg agflyer620@gwtc.net PRESIDENT White River SD SD LANDON HOSSLE JOSH HICKS Signed
251 2021-05-04 13:39 Anonymous (not verified) 159.242.43.24 Parrott Distributing, Inc 1429 16th Ave SE, Lemars, IA 51031 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-05-04 Jason Parrott jlparrott@premieronline.net Lemars Plymouth IA Jenny McIntyre Josh Olson Signed (1) The corporation rejects the employers’ liability coverage. Jason Parrott jlparrott@premieronline.net President Lemars Plymouth IA Jenny McIntyre Josh Olson Signed
601 2023-02-16 16:08 Anonymous (not verified) 94.188.207.223 Friday After Work LLC 2526 Rainbow Drive, Cedar Falls, IA 50613 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-01 Tyler Reynolds tyler.cve@gmail.com Cedar Falls Black Hawk Iowa Brady Huls Joshua Carder Signed (1) The corporation rejects the employers’ liability coverage. Brent Dunlop fawconstruction.ia@gmail.com Owner Cedar Falls Black Hawk Iowa Brady Huls Joshua Carder Signed
602 2023-02-16 16:10 Anonymous (not verified) 94.188.207.228 Friday After Work LLC 2526 Rainbow Drive, Cedar Falls, IA 50613 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-01 Brady John Huls brady.cve@gmail.com Cedar Falls Black Hawk Iowa Tyler Reynolds Joshua Carder Signed (1) The corporation rejects the employers’ liability coverage. Brent Dunlop fawconstruction.ia@gmail.com Owner Cedar Falls Black Hawk Iowa Tyler Reynolds Joshua Carder Signed
878 2024-02-02 15:22 Anonymous (not verified) 94.188.207.223 Open Road Driving School.com INC 2418 Paradise Ct Kalona, Iowa 52247 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-02 Ryan Turner ryanturner@citypoint.cc Kalona Washington IOwa Lonnie Slaubaugh Joshua Turner Signed (1) The corporation rejects the employers’ liability coverage. Ryan Turner ryanturner@citypoint.cc Secretary Kalona Washington Iowa Lonnie Slabaugh Joshua Turner Signed
879 2024-02-02 15:24 Anonymous (not verified) 94.188.205.169 Open Road Driving School.com INC 2418 Paradise Ct Kalona, Iowa 52247 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-02 Jennifer Turner jenny@openroaddrivingschool.com Kalona Washington Iowa Lonnie Slabaugh Joshua Turner Signed (1) The corporation rejects the employers’ liability coverage. Jennifer Turner jenny@openroaddrivingschool.com president Kalona Washington Iowa Lonnie Slabaugh Joshua Turner Signed
567 2022-11-14 18:21 Anonymous (not verified) 166.181.83.71 Beasts Bussiness 1305 N 6th St Apt. 6 Indianola, IA 50125 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-14 Jonathan Brice Robinson Beastsbeekeeping@gmail.com Indianola Warren Iowa Timothy Williams Robinson Josiah Grant Robinson Signed (1) The corporation rejects the employers’ liability coverage. Jonathan Brice Robinson Beastsbeekeeping@gmail.com Owner Indianola Warren Iowa Timothy Williams Robinson Josiah Grant Robinson Signed
28 2020-01-07 14:23 Anonymous (not verified) 204.155.62.177 Money Handling Machines PO Box 34218, Omaha NE 68134-0128 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation 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. 2020-01-01 David Jame Grimes daveg@moneyhandlingmanchines.com Omaha Douglas Nebraska Michael Bowman Joy Nickolte Signed (1) The corporation rejects the employers’ liability coverage. David James Grimes daveg@moneyhandlingmachines.com President Omaha Douglas NE Michael Bowman Joy Nickolite Signed
29 2020-01-07 14:24 Anonymous (not verified) 204.155.62.177 Money Handling Machines PO Box 34218, Omaha NE 68134-0128 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation 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. 2020-01-01 Scott Grimes daveg@moneyhandlingmanchines.com Omaha Douglas Nebraska Michael Bowman Joy Nickolte Signed (1) The corporation rejects the employers’ liability coverage. David James Grimes daveg@moneyhandlingmachines.com President Omaha Douglas NE Michael Bowman Joy Nickolite Signed
30 2020-01-07 14:26 Anonymous (not verified) 204.155.62.177 Money Handling Machines Inc PO Box 34218 , OMaha NE 68134 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation 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. 2020-01-01 Scott Grimes daveg@moneyhandlingmanchines.com Omaha Douglas Nebraska Michael Bowman Joy Nickolte Signed (1) The corporation rejects the employers’ liability coverage. Dave Grimes daveg@moneyhandlingmachines.com President Omaha Douglas NE Michael Bowman Joy Nickolite Signed
31 2020-01-07 14:30 Anonymous (not verified) 204.155.62.177 Money Handling Machines Inc PO Box 34218 , OMaha NE 68134 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-01-01 Mark Grimes daveg@moneyhandlingmanchines.com Omaha Douglas Nebraska Michael Bowman Joy Nickolte Signed (1) The corporation rejects the employers’ liability coverage. Dave Grimes daveg@moneyhandlingmachines.com President Omaha Douglas NE Michael Bowman Joy Nickolite Signed
76 2020-05-04 10:24 Anonymous (not verified) 173.191.207.202 Tim Fitzgerald Mechanical Services, Inc. 724 1st Ave W - 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. 2020-04-24 Tim Fitzgerald jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent-English Insurance Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
80 2020-05-11 12:29 Anonymous (not verified) 173.191.207.202 J&D Furniture-Land Corp 144 1st Ave East - 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. 2020-05-07 Scott Hittenmiller dparsons@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Joyce Heims jheims@english-insurance.com agent-English Insurance Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
82 2020-05-18 15:16 Anonymous (not verified) 184.80.177.137 Farmers Best Popcorn, LLC 110 1st Street North, - Worthington, IA 52078 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-05-18 Jon Ramaekers jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Joyce Heims jheims@english-insurance.com self Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
129 2020-10-30 11:23 Anonymous (not verified) 184.80.177.137 Haberdash Outfitters, Inc. 109 1st Ave East - 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. 2020-10-27 Jennifer Recker jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
144 2020-12-04 12:02 Anonymous (not verified) 184.80.177.137 Arlen, LLC 322 6th St SE - Dyersville, Iowa 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. 2020-12-04 Dan Arlen jheims@english-insurance.com Dyersville IA IA Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Joyce Heims joyce.heims1@gmail.com agent Dyersville IA IA Derrick Parsons Joyce Heims Signed
396 2022-02-01 10:03 Anonymous (not verified) 184.80.177.137 LKB Holdings, LLC P.O. box 313 - Monona, Ia 52159 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-29 Kandi Gillitzer jheims@english-insurance.com Monoa Clayton Iowa Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com self Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
413 2022-02-23 16:31 Anonymous (not verified) 184.80.177.137 T-Rex Hospitality LLC, DBA FUSE 120 Twin Steeples Circle, Dyersville Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-23 Tara Rahe jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
436 2022-03-29 11:07 Anonymous (not verified) 184.80.177.137 Adam Sheppard 22194 260th St - Delhi, Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-24 Adam Sheppard jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Adam Sheppard jheims@english-insurance.com agent Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
448 2022-04-19 15:15 Anonymous (not verified) 184.80.177.137 Andrew Lemke DBA: TAP Fabrication 27214 218th Street, Earlville, IA 52041 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-08 Andrew Lemke jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
515 2022-07-19 10:06 Anonymous (not verified) 184.80.177.137 Mom Clean, LLC 4 East 3rd Street - Earlville, IA 52041 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-18 Morgan Lahr dparsons@english-insurance.com Dyersville Delaware IA Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com self Dyersville Dubuque IA Derrick Parsons Joyce Heims Signed
541 2022-09-23 13:13 Anonymous (not verified) 184.80.177.137 Tim & Lori Daly 25430 New Vienna Rd - Farley, IA 52046 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-23 Tim Daly jheims@english-insurance.com Dyersville Dubuque IA Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque IA Derrick Parsons Joyce Heims Signed
509 2022-07-05 13:51 Anonymous (not verified) 96.31.7.128 KROESE CONSTRUSTION INC. 822 7TH STREET I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-06 DAVID A KROESE dkkroese@hotmail.com Hull Sioux Iowa MATTHEW ROETMAN JOYCE VANDER WELL Signed (1) The corporation rejects the employers’ liability coverage. SCOTT I KROESE scottkroese@hotmail.com vice president HULL SIOUX IOWA MATTHEW ROETMAN JOYCE VANDER WELL Signed