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 |
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 |
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 |
946 |
2024-04-04 11:53 |
Anonymous (not verified) |
94.188.205.169 |
Soto Stone LLC |
1071 Mansfield dr waukee iowa 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. |
(2) I decline to reject the employer’s liability coverage. |
2024-04-04 |
Yesser Lenin Juarez Soto |
sotostonellc95@gmail.com |
Waukee |
DALLAS |
Iowa |
Ashley Marie Francisco |
Vincent Alexander Flores |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Yesser Lenin Juarez Soto |
sotostonellc95@gmail.com |
Self |
Waukee |
Dallas |
Iowa |
Ashley Marie Francisco |
Vincent Alexander Flores |
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 |
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 |
259 |
2021-05-06 11:00 |
Anonymous (not verified) |
76.79.44.61 |
Woltemath Farm Inc |
3096 300th Ave, Hamburg, Ia 51640 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or 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 |
Sandra Lynn Graybill |
sndygra@gmail.com |
Council Bluffs |
Pottawattamie |
United States |
Lisa Reinier |
Sheryl Owen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Woltemath |
rwoltem@gmail.com |
Officer/ Owner |
Hamburg |
Fremont |
IA |
Lisa Reinier |
Sheryl Owen |
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 |
483 |
2022-06-02 08:28 |
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 |
Deb Sylvester |
judy@fullenkampins.com |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Deb Sylvester |
judy@fullenkampins.com |
Secretary / Treasurer |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
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 |
707 |
2023-07-10 12:50 |
Anonymous (not verified) |
94.188.207.228 |
Gaytán Framing |
5303 Brook Landing Cir Des Moines Ia 50317 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-07-10 |
Jose Gaytán Ruiz |
pedro.j.zelaya@gmail.com |
Des moines |
Polk |
Iowa |
Pedro zelaya |
Yeraldi Nabor |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jose Gaytán Ruiz |
pedro.j.zelaya@gmail.com |
Owner |
Des moines |
Polk |
Iowa |
Pedro Zelaya |
Yeraldi nabor |
Signed |
819 |
2023-11-16 14:25 |
Anonymous (not verified) |
94.188.205.167 |
T&R Drywall LLC |
1450 NE 69th Pl Ste 56 Ankeny, IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-16 |
Jorge Marquez Soto |
Special.t.d@hotmail.com |
Des Moines |
Polk |
IA |
Omar L Tippetts |
Omar L Tippetts Jr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
N/A |
special.t.d@hotmail.com |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
Signed |
962 |
2024-04-26 08:46 |
Anonymous (not verified) |
94.188.207.225 |
Gilbert Construction |
3174 Hwy F48 West Newton, Iowa 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. |
2024-04-26 |
Christian Gilbert |
christian.gilbert14@gmail.com |
Newton |
Jasper |
Iowa |
Leslie Gilbert |
Shane Gilbert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christian Gilbert |
christian.gilbert14@gmail.com |
worker |
Altoona |
polk |
iowa |
Leslie Gilbert |
Shane Gilbert |
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 |
163 |
2021-01-20 11:08 |
Anonymous (not verified) |
173.233.46.58 |
Wasmer Post 241 Department of Iowa dba The American Legion |
110 Plymouth St SW, Le Mars, 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. |
2021-01-13 |
Kim Wittmar |
mrkmjm@yahoo.com |
Le Mars |
Plymouth |
iA |
Muriel J. MIller |
Richard P. Miller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gary L. Konz |
claim_buster@yahoo.com |
Financial Officer |
Le Mars |
Plymouth |
IA |
Muriel J. Miller |
Richard P. Miller |
Signed |
275 |
2021-06-15 13:23 |
Anonymous (not verified) |
172.98.131.84 |
JAVIER CONSTRUCTION INC |
2503 Canyon 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. |
2021-06-15 |
Javier Adana |
Javierconstruction88@gmail.com |
CEDAR RAPIDS |
LINN |
IOWA |
JASON SCHICK |
LADONNA SCHICK |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
JASON SCHICK |
JASONSCHICK@NEIGHBORINSURANCE.COM |
INSURANCE AGENT |
CEDAR RAPIDS |
LINN |
IOWA |
JASON SCHICK |
LADONNA SCHICK |
Signed |
387 |
2022-01-11 11:11 |
Anonymous (not verified) |
216.51.165.122 |
M & K Rentals Inc |
800 Country Club Dr, 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. |
2021-12-20 |
Mark F Intlekofer |
kmintlekofer@yahoo.com |
MAQUOKETA |
Jackson |
Iowa |
Rachelle Zeimet |
Justin Meade |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mark F Intlekofer |
kmintlekofer@yahoo.com |
President |
Maquoketa |
Jackson |
Iowa |
Rachelle Zeimet |
Justin Meade |
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 |
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 |
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 |
835 |
2023-12-13 08:41 |
Anonymous (not verified) |
94.188.207.226 |
J&M Tire and Repair LLC |
31006 hedge ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-12-13 |
Jacob Mills Barkley |
jmtireandrepair@gmail.com |
sioux city |
Iowa |
United States |
Evan Cook |
Kevin Vothj |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jacob Mills Barkley |
jmtireandrepair@gmail.com |
Owner |
sioux city |
Iowa |
United States |
Evan Cook |
Kevin Voth |
Signed |
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 |
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 |
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 |
291 |
2021-07-26 12:31 |
Anonymous (not verified) |
208.95.1.97 |
Chyma's Welding, Inc. |
206 2nd Ave, Toledo IA 52342 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-01 |
Chad Chyma |
Chymamenwelding@windstream.net |
Toledo |
Tama |
Iowa |
Matt Zmolek |
Michaela Chyma |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chad Chyma |
Chymamenwelding@windstream.net |
Director |
Toledo |
Tama |
Iowa |
Matt Zmolek |
Michaela Chyma |
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 |
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 |
627 |
2023-03-17 06:48 |
Anonymous (not verified) |
94.188.207.229 |
Hearing Health Care, LLC |
2519 South 16th Street Council Bluffs, IA 51501 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-17 |
Melissa Ann Knoell |
melissaknoell@yahoo.com |
Council Bluffs |
Pottowattomi |
Iowa |
Bruce Carol Johnk |
Marcelyn Maureen Johnk |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Melissa Ann Knoell |
melissaknoell@yahoo.com |
Self |
Council Bluffs |
Pottawattomi |
Iowa |
Bruce Carol Johnk |
Marcelyn Maureen Johnk |
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 |
851 |
2024-01-14 15:40 |
Anonymous (not verified) |
94.188.205.169 |
B St. Construction + Design, Inc. |
16 Southwest 42nd Street |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-13 |
Emily Renze-Crouch |
emily@bstdesigner.com |
Des Moines |
Iowa |
United States |
Jodi Essex |
Linda K Renze |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Emily Renze-Crouch |
emily@bstdesigner.com |
Vice President / CFO |
Des Moines |
IA |
United States |
Jodi Essex |
Linda K Renze |
Signed |
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 |
195 |
2021-03-02 16:29 |
Anonymous (not verified) |
173.29.156.163 |
Certified drywall |
329 e.11th 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. |
(1) I reject the employers’ liability coverage. |
2021-03-02 |
Thomas wells |
mikeparry783@gmail.com |
Davenport |
Scott |
Iowa |
Chyna rose pena |
Natalie parry |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Thomas wells |
mikeparry783@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Chyna rose pena |
Natalie parry |
Signed |
307 |
2021-08-13 15:21 |
Anonymous (not verified) |
65.154.100.34 |
World of Reptiles Inc dba Snakes Alive |
3901 NW Seasons Ct 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. |
2021-08-09 |
Ron Goodman |
ron_goo@msn.com |
Ankeny |
Polk |
IA |
Megan Matlock |
Tom Weidner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ron Goodman |
ron_goo@msn.com |
Owner |
Ankeny |
Polk |
IA |
Megan Matlock |
Tom Weidner |
Signed |
419 |
2022-03-03 14:37 |
Anonymous (not verified) |
68.13.47.145 |
Trility Group Holdings, Inc |
14001 University Ave, Suite 300 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or 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 |
James Brody Deren |
brody@trility.io |
Omaha |
Douglas |
Nebraska |
Devin Boyer |
Kyle Woiwood |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Brody Deren |
brody@trility.io |
Secretary |
Omaha |
Douglas |
Nebraska |
Devin Boyer |
Kyle Woiwood |
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 |
643 |
2023-03-30 09:58 |
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. |
2023-03-30 |
Emily Wallace |
emily.wallace@spinemoving.com |
Des Moines |
Polk |
Iowa |
John Wallace |
Ashley Koch |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ashley Koch |
ashley.koch@spinemoving.com |
Human Resources Manager |
West Des Moines |
Polk |
Iowa |
John Wallace |
Taylor Roth |
Signed |
755 |
2023-08-25 11:34 |
Anonymous (not verified) |
94.188.205.169 |
Paralax Corporation dba Beck Electric |
8646 103rd 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. |
2023-08-25 |
Jonathan Beck |
jon@beck-electric.com |
Indianola |
Warren |
Iowa |
Stephanie Watkins-Beck |
Michael Beck |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jonathan Beck |
jon@beck-electric.com |
Owner |
Indianola |
Warren |
Iowa |
Stephanie Watkins-Beck |
Michael Beck |
Signed |
867 |
2024-01-24 15:04 |
Anonymous (not verified) |
94.188.207.227 |
Shook Handyman |
2415 Plum Creek Rd |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-24 |
Nolan Shook |
office@shookhandyman.com |
Sioux City |
Woodbury |
IA |
McKenna Warner |
Jessica Shook |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Susan Geist |
sgeist@paychex.com |
Paychex Insurance Agency Inc |
Rochester |
Monroe |
NY |
Nolan Shook |
McKenna Warner |
Signed |
898 |
2024-02-24 21:06 |
Anonymous (not verified) |
94.188.207.226 |
Under Pressure Pressure on |
1008 Doubletree 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. |
2024-02-24 |
Kevin M Feeney |
kevin.feeney45@gmail.com |
Cedar Rapids |
IA |
United States |
Taryn Erbes |
Susan Erbes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kevin M Feeney |
kevin.feeney45@gmail.com |
Owner |
Cedar Rapids |
IA |
United States |
Taryn Erbes |
Susan Erbes |
Signed |
99 |
2020-07-12 13:29 |
Anonymous (not verified) |
207.32.58.202 |
Subject Enterprise, Inc. |
165 210th St Wesley, IA 50483 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-12 |
Coda Subject |
subjectenterprise@gmail.com |
Britt |
Hancock |
IA |
Keri Byom |
Steve Schlichting |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Coda Subject |
subjectenterprise@gmail.com |
Owner |
Britt |
Hancock |
IA |
Keri Byom |
Steve Schlichting |
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 |
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 |