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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:
182 2021-02-18 08:52 Anonymous (not verified) 173.18.193.51 Freeman Family Farms Inc 3125 Glasgow Rd Fairfield Iowa 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. 2021-02-08 Bradly Freeman jill@fullenkampins.com Mt. Pleasant Henry Iowa Jill A Garmoe Judy K Moeller Signed (1) The corporation rejects the employers’ liability coverage. Bradly Freeman jill@fullenkampins.com Treasurer Mt Pleasant Henry Iowa Jill A Garmoe Judy K Moeller Signed
294 2021-07-27 14:10 Anonymous (not verified) 173.19.179.111 MILFORD MECHANICAL INC 1607 L AVE MILFORD, IA 51351 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-06-14 DUSITN BOER joel@walkerinsuranceia.com MILFORD DICKINSON IOWA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The corporation rejects the employers’ liability coverage. DUSTIN BOER joel@walkerinsuranceia.com PRESIDENT MILFORD DICKINSON IOWA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
406 2022-02-15 17:30 Anonymous (not verified) 173.18.126.91 Huff Construction 1309 Business 30 sw Mount Vernon IA I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-15 Jason Huff jason@huff-construction.com Mount Vernon Linn Iowa Katie Huff Rick Deneve Signed (1) The corporation rejects the employers’ liability coverage. Jason Huff jason@huff-construction.com Owner Mount Vernon Linn Iowa Katie Huff Rick Deneve Signed
518 2022-07-21 10:58 Anonymous (not verified) 75.162.31.164 Bengard Roofing LLC 1927 Wethersfield Dr, Norwalk, IA 50211 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-21 Brandon Bengard bj@bengardroofing.com Norwalk Warren IA Rebecca Bengard Juhl Bengard Signed (1) The corporation rejects the employers’ liability coverage. Brandon Bengard bj@bengardroofing.com Owner Norwalk Warren IA Becky Bengard Juhl Bengard Signed
630 2023-03-21 21:32 Anonymous (not verified) 94.188.205.169 S & O Builders, LLC 201 NW 10th Circle, Grimes, IA 50111 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-21 Benjamin Olson sandobuilders@gmail.com Grimes IA IA Brad Fasse Nate Estes Signed (1) The corporation rejects the employers’ liability coverage. Benjamin Olson sandobuilders@gmail.com Co-Owner Grimes IA IA Brad Fasse Nate Estes Signed
933 2024-03-22 21:55 Anonymous (not verified) 94.188.205.176 Alternative Sport Enterprises 101 Highway 1 West 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. 2024-03-22 James Michael Pearson hatchetjacksiowa@gmail.com Savage Scott County Minnesota Payton Kahl Trey Kahl Signed (1) The corporation rejects the employers’ liability coverage. Nick John Carroll hatchetjacksiowa@gmail.com Owner CORALVILLE Johnson County Iowa Payton Kahl Trey Kahl 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
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
86 2020-06-03 17:56 Anonymous (not verified) 75.162.69.231 Blackford Foundations Inc 501 SW Franklin Dr, 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. 2020-05-01 Denny Lee Blackford blackfordfoundations@gmail.com Ankeny Polk Iowa Saree Luce Ricky Eatwell Signed (1) The corporation rejects the employers’ liability coverage. Denny Lee Blackford blackfordfoundations@gmail.com Secretary Ankeny Polk Iowa Saree Luce Ricky Eatwell Signed
198 2021-03-03 17:14 Anonymous (not verified) 173.29.156.163 Jdw 329 E. 11th st 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. 2021-03-03 James holzer slickninja00@gmail.com Davenport Scott Iowa Alyssa holzer Kory munn Signed (2) The corporation declines to reject the employers’ liability coverage. James holzer slickninja00@gmail.com Myself Davenport Scott Iowa Alyssa holzer Kory munn 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
422 2022-03-08 08:56 Anonymous (not verified) 98.16.51.166 Trility Group Holdings, Inc. 14001 University Avenue, Suite 300, Clive IA 50125 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-08 Matthew D Edwards matthew@trility.io New Virginia Warren Iowa Devin Boyer Kyle Woiwood Signed (1) The corporation rejects the employers’ liability coverage. Matthew D Edwards matthew@trility.io President New Virginia Warren Iowa Devin Boyer Kyle Woiwood Signed
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
646 2023-03-31 13:58 Anonymous (not verified) 94.188.205.168 American Residential Services Inc 1683 Elizabeth Dr 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. 2023-03-31 Robert Rettmann americanres@yahoo.com Apple Valley Dakota MN Nancy Rettmann William Dilts Signed (1) The corporation rejects the employers’ liability coverage. Robert Rettmann americanres@yahoo.com President Apple Valley Dakota MN Nancy Rettmann William Dilts 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
758 2023-08-29 11:56 Anonymous (not verified) 94.188.207.229 Ellison building and repair 2722 645th moravia IA 52571 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-18 Keeton Ellison keeton2005@gmail.com Moravia Appanoose Iowa Cory Ellison Sammy Ellison Signed (1) The corporation rejects the employers’ liability coverage. Sammy Ellison sammyllsn@yahoo.com Mom Moravia Monroe Iowa Cory Ellison Sammy Ellison 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
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
214 2021-03-28 12:59 Anonymous (not verified) 172.86.34.18 Agronomic Solutions, INC 1614 Fir Avenue Coon Rapids, IA 50058 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or 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 Nickolas Lee Steffens nsteffens@agsolutionsinc.net Quasqueton Buchanan Iowa Julia Sperfslage Andrew Sperfslage Signed (1) The corporation rejects the employers’ liability coverage. Nickolas Lee Steffens nsteffens@agsolutionsinc.net Owner/ Vice President Quasqueton Buchanan Iowa Andrew Sperfslage Julia Sperfslage Signed
326 2021-09-03 12:56 Anonymous (not verified) 173.19.58.159 Oskaloosa Entertainment Inc. 507 High Ave W Oskaloosa, IA 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. 2021-08-11 Rajan Devan djraj007@gmail.com West Des Moines Polk Iowa Joe Mauro Randy Mauro Signed (2) The corporation declines to reject the employers’ liability coverage. Joe Mauro joe@mauroinsurance.net insurance agent DES MOINES Polk United States Joe Mauro Randy Mauro Signed
438 2022-03-29 16:28 Anonymous (not verified) 209.180.36.109 Sani Enterprise 101 Ashworth Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-29 Azmir Alic ale_boss00@hotmail.com Urbandale polk iowa Azmir Alic Andrew Swanson Signed (1) The corporation rejects the employers’ liability coverage. Andrew Swanson sanienterprise14@gmail.com Director of Operations Granger Dallas Iowa Andrew Swanson Sandro Tadic Signed
550 2022-09-29 09:10 Anonymous (not verified) 208.126.212.128 City of Leland 316 Walnut St., PO Box 127, Leland, IA 50453 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-29 Russell Leitz rkleitz@wctatel.net Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed (1) The corporation rejects the employers’ liability coverage. Dawn Arispe leland@wctatel.net City of Leland City Clerk Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed
662 2023-05-01 14:36 Anonymous (not verified) 94.188.207.230 RH tile stone 1403 Ne Falstaff 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. 2023-05-01 Raif Hadzic rh-tile@outlook.com Ankeny Polk Iowa Mario demarco Raif Hadzic Signed (1) The corporation rejects the employers’ liability coverage. Raif Hadzic rh-tile@outlook.com Sob contract Ankeny Polk Iowa Mario demarco Raif Hadzic Signed
965 2024-04-30 10:47 Anonymous (not verified) 94.188.205.177 Billy Dudock 148818 Argo Fay 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. 2024-04-30 Billy Dudock mitzi@bruggemanlumber.com Thompson Carroll IL Roger Gibbs Mitzi Hoeger Signed (1) The corporation rejects the employers’ liability coverage. Billy Dudock mitzi@bruggemanlumber.com Self Thompson Carroll Il Roger Gibbs Mitzi Hoeger 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
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
118 2020-09-15 14:32 Anonymous (not verified) 174.243.115.133 Jurisdiction Approved Plumbing Corporation P.O. Box 343 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-15 Christian m Lavia eeejumble@gmail.com Urbandale Polk Iowa Tina m Heuckendorf Roslyn Heuckendorf Signed (1) The corporation rejects the employers’ liability coverage. Christian m Lavia eeejumble@gmail.com Director Urbandale Polk IOWA Tina m Heuckendorf Roslyn Heukendorf 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
342 2021-10-06 11:02 Anonymous (not verified) 192.95.124.125 Jeffrey Wilharm MDPC 9100 C St., Cedar Rapids, IA 52404-9160 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-10-06 Jeffrey Wilharm wilharmjeffrey@gmail.com Cedar Rapids Linn IA John Yundt Lori Smith Signed (1) The corporation rejects the employers’ liability coverage. Jeffrey Wilharm wilharmjeffrey@gmail.com President Cedar Rapids Linn IA John Yundt Lori Smith Signed
454 2022-04-26 14:03 Anonymous (not verified) 216.106.225.224 Kevin Knapp 2227 120th Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-26 Nathan Glenn Knapp knapptimedairy@gmail.com larchwood lyon ia Eric TeGrootenhuis Lisa Faber Signed (1) The corporation rejects the employers’ liability coverage. Kevin Knapp knapptimedairy@gmail.com owner Larchwood Iowa United States Eric TeGrootenhuis Lisa Faber Signed
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
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
790 2023-10-17 14:16 Anonymous (not verified) 94.188.205.166 Reform exteriors 326 1st street mason 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. 2023-10-16 Manuel g ramos ramosm943@gmail.com IA Cerro gordo Iowa Manuel ramos Manuel ramos Signed (1) The corporation rejects the employers’ liability coverage. Manuel g ramos ramosm943@gmail.com Owner Iowa Cerro gordo Iowa Manuel ramos Manuel ramos 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
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
246 2021-04-22 10:56 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. 2021-04-22 Mary Thompson becky@fgains.com Clear Lake Cerro Gordo Iowa Debbie Otto Paxton Farmer Signed (1) The corporation rejects the employers’ liability coverage. Brad Thompson becky@fgains.com Owner Clear Lake Cerro Gordo Iowa Debbie Otto Paxton Farmer Signed
358 2021-11-15 09:39 Anonymous (not verified) 165.225.57.41 Jerry Steward Trucking Inc. 319 W. 7th Street, Janesville, IA 50647 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-10-22 Jerry Steward Sr. cedarfalls.oil@gmail.com Cedar Falls Black Hawk Iowa Meredith Morrow Susan Fiser Signed (1) The corporation rejects the employers’ liability coverage. Jerry Steward Jr. cedarfalls.oil@gmail.com Vice-President Cedar Falls Black Hawk Iowa Meredith Morrow Susan Fiser Signed
470 2022-05-12 14:28 Anonymous (not verified) 173.184.134.123 Bryce Hoffert LLC 1802 Lake Street Emmetsburg Iowa 50536 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-12 Bryce C Hoffert brycehoffertllc@gmail.com Emmetsburg Pala Alto Iowa Ray Hoffert Shelbie Hurdle Signed (1) The corporation rejects the employers’ liability coverage. Bryce Hoffert brycehoffertllc@gmail.com member Emmetsburg Palo Alto Iowa Ray Hoffert Shelbie Hurdle Signed
582 2022-12-09 11:26 Anonymous (not verified) 74.84.79.78 Diamond Does It LLC 3945 38th St. Des Moines, IA 50310 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-01 Daimond Martinez diamonddoesitdsm@gmail.com Des Moines Polk Iowa Michael O'Conner Ron Rand Signed (1) The corporation rejects the employers’ liability coverage. Diamond Martinez diamonddoesitdsm@gmail.com Owner Des Moines Polk Iowa Michael O'Conner Ron Rand Signed
694 2023-06-20 13:25 Anonymous (not verified) 94.188.207.229 Canvas Products Co. 182 Main Street Dubuque, Iowa 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. 2023-06-20 Frank Salwolke frank@dbqcanvas.com Dubuque IA Iowa Ashley A. Trowbridge Taylor J. Trowbridge Signed (1) The corporation rejects the employers’ liability coverage. frank salwolke frank@dbqcanvas.com President DUBUQUE IA Iowa Ashley A. Trowbridge Taylor J. Trowbridge 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
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
150 2020-12-31 15:00 Anonymous (not verified) 216.81.153.249 S&A Holdings LLC 115 N 2nd Street, Fort Dodge, IA 50501 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-21 Amritpal Singh amritaust1@gmail.com Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Amritpal Singh amritaust1@gmail.com Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
262 2021-05-06 12:50 Anonymous (not verified) 65.158.43.250 Maxter Roofing INC 4112 E 14th St Des Moines, IA 50313 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or 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 Gilberto Mata DBA Maxter Roofing INC oliviazavala120@yahoo.com Des Moines Polk IA Josh Bolton Olivia Zavala Signed (1) The corporation rejects the employers’ liability coverage. Gilberto Mata DBA Maxter Roofing INC oliviazavala120@yahoo.com Owner Des Moines POLK IA Josh Bolton Olivia Zavala 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
486 2022-06-02 08:34 Anonymous (not verified) 173.18.193.51 Wever Fire Association 1692 354th Avenue, Wever, Iowa 52658 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-24 Craig Pieper judy@fullenkampins.com Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Craig Pieper Judy@fullenkampins.com Vice President Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed
598 2023-02-10 09:38 Anonymous (not verified) 94.188.207.225 Y & M Cleaning Services Inc. 4380 SE 15th Ct I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-02-10 Martine Martinez martinmtzmartinez@gmail.com Des Moines Polk Iowa Suzanne E Collier Andy Boyd Signed (1) The corporation rejects the employers’ liability coverage. Suzanne E Collier scollie1@amfam.com Non Related Altoona Polk IA Andy Boyd Martin Martinez Signed
901 2024-02-26 11:02 Anonymous (not verified) 94.188.207.227 roorda dairy llc 5128 460th 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. 2024-02-22 larry roorda lgroorda@gmail.com paullina obrien county iowa lance roorda scott roorda Signed (1) The corporation rejects the employers’ liability coverage. kyle blankers kyle@veinsurance.com member 5128 460th st obrien county iowa lance roorda scott roorda Signed
710 2023-07-21 08:26 Anonymous (not verified) 94.188.205.169 Dream Team Anesthesia, Inc. 2800 E. Enterprise Ave, Ste 333, Appleton, WI 54913 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-21 Jesse Chiu jessechiu2@yahoo.com Sterling Whiteside IL Joseph Chiu Kin Chiu Signed (1) The corporation rejects the employers’ liability coverage. Jesse Chiu jessechiu2@yahoo.com President Waterloo Polk Iowa Joseph Chiu Kin Chiu Signed
822 2023-11-20 09:43 Anonymous (not verified) 94.188.207.223 Lifeson LLC 303 6th Ave Coralville IA 52241 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-14 Scott Parshall scott@lifeson.com Coralville Johnson Iowa Samantha Mlavsky Pamela Mahon Signed (1) The corporation rejects the employers’ liability coverage. Scott Parshall scott@lifeson.com member Coralville Johnson Iowa Samantha Mlavsky Pamela Mahon Signed