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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:
794 2023-10-18 08:21 Anonymous (not verified) 94.188.205.177 J&M Tire and Repair 31006 hedge ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-18 Macklin Paul Barkley flyingtank92@yahoo.com merrill Iowa United States Brandon Norris Alex Barkley Signed (1) The corporation rejects the employers’ liability coverage. Macklin Paul Barkley jmtireandrepair@gmail.com Owner sioux city Iowa United States Brandon Norris Alex Barkley Signed
26 2020-01-07 11:00 Anonymous (not verified) 208.95.1.97 Rumours Sports Bar & Grill 309 N 12th Ave Place Marshalltown IA 50158 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2019-11-07 Jason Priske darla.rowley@insurecentraliowa.com Marshalltown Marshall Iowa Darla Rowley Samantha Garrison Signed (1) The corporation rejects the employers’ liability coverage. Jason Priske darla.rowley@insurecentraliowa.com Owner Marshalltown Marshall Iowa Darla Rowley Samantha Garrison Signed
138 2020-11-24 14:11 Anonymous (not verified) 173.215.17.41 Dohrmann Enterprises, Inc 2478 260th Ave. DeWitt, Iowa 52742 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-11-24 Joel Dohrmann dohrmannpnh@gmail.com DE WITT Clinton IA Susanne Owen Daron Oberbroecking Signed (1) The corporation rejects the employers’ liability coverage. Susanne Owen sowen@ohnward.com none Camanche Clinton Iowa Joel Dohrmann Daron Oberbroecking Signed
250 2021-05-04 10:19 Anonymous (not verified) 216.81.153.249 K Drey Ag LLC 2242 Hope Ave, Early, IA 0535 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-05-04 Kennedy Drey kdreyag@gmail.com Early Sac Iowa Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Kennedy Drey kdreyag@gmail.com Owner Early Sac Iowa Jared Brashears Mary Jo Olthoff Signed
362 2021-11-16 11:20 Anonymous (not verified) 63.227.65.43 F&H Aluminum, Inc. 101 E. Corporate Drive Charles City, Iowa 50616 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-11-16 DeWayne Ferch fhaluminum@netconx.net Kensett Worth Iowa Tom Stephany Amanda Korenberg Signed (1) The corporation rejects the employers’ liability coverage. DeWayne Ferch fhaluminum@netconx.net President Kensett Worth Iowa Tom Stephany Amanda Korenberg Signed
474 2022-05-16 16:25 Anonymous (not verified) 208.126.193.1 Gentle Bend Inc. 1075 120th Street, Wellman, Iowa 52356 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-16 Georgia Gent ggent83@gmail.com Wellman Washington Iowa Jeff Spenner Shawn Powell Signed (1) The corporation rejects the employers’ liability coverage. Georgia Gent ggent83@gmail.com owner Wellman Washington Iowa Jeff Spenner Shawn Powell Signed
937 2024-03-30 17:30 Anonymous (not verified) 94.188.205.167 AR Drilling LLC 1821 Roebling Rd, Adel, IA 50003 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-30 Luis Serrano serranoluis7667@gmail.com Adel Dallas IA Kelly green Thomas Green Signed (1) The corporation rejects the employers’ liability coverage. Luis Serrano serranoluis7667@gmail.com Owner Adel Dallas IA Kelly Green Thomas Green Signed
586 2022-12-16 15:53 Anonymous (not verified) 184.184.197.146 Halide Biologics 330 Golfview Ave, Iowa City IA 52246 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-12-15 Daniel Infield danielinfield@gmil.com Bennington Douglas Nebraska Alexander Estell Jesse Herrera Signed (1) The corporation rejects the employers’ liability coverage. Daniel Infield danielinfield@gmail.com President Bennington NE United States Alexander Estell Jesse Herrera Signed
698 2023-06-21 07:46 Anonymous (not verified) 94.188.207.223 Jesus Rodriguez 2210 E. Rose Avenue Apt. 30 Des Moines, Iowa 50320 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-21 Jesus Rodriguez jesus.jr4514@gmail.com Des Moines Polk Iowa Veronica Rodriguez Daniel Gallardo Signed (1) The corporation rejects the employers’ liability coverage. Jesus Rodriguez jesus.jr4514@gmail.com Owner Des Moines Polk Iowa Veronica Rodriguez Daniel Gallardo Signed
810 2023-11-09 17:41 Anonymous (not verified) 94.188.205.167 Chad Ripple's Painting LLC 899 NW 45th Ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-09 Chad Ripple ia515@hotmail.com Des Moines Polk Iowa Ron Spurgeon Brandon Haus Signed (1) The corporation rejects the employers’ liability coverage. Chad Ripple ia515@hotmail.com President Des Moines Polk Iowa Ron Spurgeon Brandon Haus Signed
42 2020-02-16 19:13 Anonymous (not verified) 207.199.193.217 S J Hernandez, Inc 19738 133rd Street Bloomfield, IA 52537 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-02-16 Salvador Hernandez-Perez jessieatcjs@gmail.com Bloomfield Davis Iowa Jessica Hernandez Joseph Olinger Signed (1) The corporation rejects the employers’ liability coverage. Salvador Hernandez-Perez jessieatcjs@gmail.com Owner Bloomfield Davis Iowa Jessica Hernandez Joseph Olinger Signed
154 2021-01-06 13:23 Anonymous (not verified) 167.142.147.6 PACIFIC DRYWALL CORPORATION 105 SNYDER DRIVE HUXLEY, IOWA 50124 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2021-01-06 LUIS MANUEL AVALOS CASTELANOS PACIFICDRYWALLCORP@GMAIL.COM DES MOINES POLK IOWA JENNIFER LYNNE ESCOBAR JUAN JOSE AVALOS CASTELLANOS Signed (2) The corporation declines to reject the employers’ liability coverage. LUIS MANUEL AVALOS CASTELANOS PACIFICDRYWALLCORP@GMAIL.COM PRESIDENT DES MOINES POLK IOWA JUAN JOSE AVALOS CASTELLANOS JENNIFER LYNNE ESCOBAR Signed
266 2021-05-22 13:38 Anonymous (not verified) 75.162.162.238 Superior Painting and Remodeling, corp 8415 Franklin Ave. Apt. 49 Clive, Iowa 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-05-22 Elmer Lopez Montufar lm3673719@gmial.com Des Moines USA Iowa Yolanda Mendoza Liliana Sanchez Signed (2) The corporation declines to reject the employers’ liability coverage. Superior Painting and Remodeling Corp lm3673719@gmial.com Owner Des Moines USA Iowa Yolanda Mendoza Liliana Sanchez Signed
378 2022-01-03 15:16 Anonymous (not verified) 217.180.230.157 True360, Inc. 1805 Collaboration Place, Suite 1300, Ames, Iowa 50010 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-03 Christopher James chris@true-360.com Ames Iowa United States Jesse Kisker Cody Kapka Signed (1) The corporation rejects the employers’ liability coverage. Christopher James chris@true-360.com President and Chief Executive Officer Ames Iowa United States Jesse Kisker Cody Kapka Signed
490 2022-06-03 10:14 Anonymous (not verified) 70.96.153.153 Reicks Construction Inc 5415 Alburnett Rd, Marion, IA 52302 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-03 Victor Reicks victor@optionsexteriors.com Marion Linn County Iowa Austin Miller Charlotte Rasmussen Signed (1) The corporation rejects the employers’ liability coverage. Victor Reicks victor@optionsexteriors.com Owner Marion Linn County Iowa Austin Miller Charlotte Rasmussen Signed
953 2024-04-08 17:35 Anonymous (not verified) 94.188.205.174 Bio-Inspired Design Aeronautics Corp 6843 Still Creek Pass I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-08 Hollie Mitchell mitchhollie@yahoo.com Bettendorf Iowa United States Mike Owens Chris DeCock Signed (1) The corporation rejects the employers’ liability coverage. Joseph Mitchell aerotech@hush.com President Bettendorf Iowa United States Mike Minnich Chris DeCock Signed
602 2023-02-16 16:10 Anonymous (not verified) 94.188.207.228 Friday After Work LLC 2526 Rainbow Drive, Cedar Falls, IA 50613 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-01 Brady John Huls brady.cve@gmail.com Cedar Falls Black Hawk Iowa Tyler Reynolds Joshua Carder Signed (1) The corporation rejects the employers’ liability coverage. Brent Dunlop fawconstruction.ia@gmail.com Owner Cedar Falls Black Hawk Iowa Tyler Reynolds Joshua Carder Signed
714 2023-07-25 16:16 Anonymous (not verified) 94.188.207.224 Midwest Systems 2877 130th St Aurora, Ia 50607 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-25 Matt Griswold midwestsystems@live.com Aurora IA United States Creatleigh Griswold Carslyn Griswold Signed (1) The corporation rejects the employers’ liability coverage. Matt Griswold midwestsystems@live.com Owner Aurora IA United States Creatleigh Griswold Carslyn Griswold Signed
826 2023-11-22 08:04 Anonymous (not verified) 94.188.207.226 Sabuydee Corporation 617 Davis Ave. / Corning, IA 50841 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-22 Adam Grundman adamgrundman@gmail.com Corning Adams Iowa Carol Penglase MIchael Grundman Signed (1) The corporation rejects the employers’ liability coverage. Adam Grundman adamgrundman@gmail.com President Corning Iowa United States Carol Penglase Michael Grundman Signed
58 2020-04-14 08:32 Anonymous (not verified) 174.217.17.57 Society of St Vincent de Paul, District Counsel Waterloo Iowa 320 Broadway St PO Box 2727 Waterloo IA 50704 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-14 Rodney Crowe crorod@aol.com Waterloo Blackhawk Iowa George W Karnivk Glynis R Worthington Signed (1) The corporation rejects the employers’ liability coverage. Joseph D Sobczyk joczyk@aol.com Corporate Treasurer Cdear Falls Blackhawk Iowa George W Karnick Glynis R Worthington Signed
170 2021-01-26 12:23 Anonymous (not verified) 74.84.91.178 Sunset Ridge Winery LLC 12615 Highway 52 North, Dubuque, IA 52002 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-07 Ann Bonnette jbonnette@yahoo.com Dubuque Dubuque Iowa Derrick Parsons Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. Ann Bonnette jbonnette@yahoo.com Officer Dubuque Dubuque Iowa Derrick Parsons Brenda Lewis Signed
282 2021-06-30 12:31 Anonymous (not verified) 204.155.61.217 Stout Roofing Inc 1200 Ash St, Dallas Center, IA 50063 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-06-30 Jacob Stout jacobstout@hailmayday.com Dallas Center Dallas County IA Ashley Kraft Docusign Signed (1) The corporation rejects the employers’ liability coverage. Jacob Stout jacobstout@hailmayday.com Owner Dallas center Dallas IA Ashley Kraft Docusign Signed
394 2022-01-27 12:29 Anonymous (not verified) 72.255.65.83 Rodgers’ Building & Remodeling Inc 1003 NW 37th Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-28 Benjamin Rodgers btrdsm18@gmail.com Ankeny Polk Iowa Mary Rodgers Larry Joel Signed (1) The corporation rejects the employers’ liability coverage. Mary Rodgers steff.m2096@yahoo.com President Ankeny Polk Iowa Ben Rodgers Larry Joel Signed
506 2022-06-30 17:23 Anonymous (not verified) 209.180.36.109 Sani Enterprise 101 Ashworth Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-30 Nada Krasniqi najstor406@gmail.com Johnston Polk iowa Sandro Tadic Andy Swanson Signed (1) The corporation rejects the employers’ liability coverage. Sandro Tadic sanienterprise14@gmail.com Owner Urbandale polk iowa sandro tadic andy swanson Signed
969 2024-05-02 16:15 Anonymous (not verified) 94.188.205.175 Adamantine Spine Moving 2726 Independence Rd Iowa City, IA 52240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-02 John Clifford Wallace cliff.wallace@spinemoving.com Des Moines Polk Iowa John Thomas Wallace Amanda Root Wallace Signed (1) The corporation rejects the employers’ liability coverage. Bill Hoke bill.hoke@spinemoving.com HR Des Moines Polk County Sarah Mannix Erika Banks Signed
618 2023-03-02 20:11 Anonymous (not verified) 94.188.205.169 Lytton Flooring LLC 10459 Sunset Terrace, 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. 2023-03-01 Russell Lytton lyttoncustomtile@gmail.com Clive Polk Iowa Lisa Lytton Stella Lytton Signed (1) The corporation rejects the employers’ liability coverage. Russell Harold Lytton Lyttonflooring@gmail.com Self Clive Polk Iowa Lisa Lytton Stella Lytton Signed
730 2023-08-04 07:42 Anonymous (not verified) 94.188.207.225 Barrel Head Winery Inc 9995 Laudeville Road, Dubuque, IA 52003 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-03 Jodie Fuhreck sales@barrelheadiowa.com Dubuque Dubuque Iowa Derrick Parsons Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Jodie Fuhreck sales@barrelheadiowa.com Owner Dubuque Dubuque Iowa Derrick Parsons Derrick Parsons Signed
842 2023-12-18 16:31 Anonymous (not verified) 94.188.205.168 Brandon Clement 3503 South Union St I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-18 Brandon Clement hawthornhill@paramark.us Des Moines Polk IA Brandi Haight Amanda Thompson Signed (1) The corporation rejects the employers’ liability coverage. Brandon Clement hawthornhill@paramark.us none Des Moines polk IA Brandi Haight Amanda Thompson Signed
74 2020-04-29 05:29 Anonymous (not verified) 198.14.245.254 Clanton Creek Land Improvement 2094 Pheasant Run Trail Peru Iowa 50222 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-28 Spencer Minnich sminnich85@hotmail.com Peru Madison Iowa Sarah Minnich Travis Tuttle Signed (1) The corporation rejects the employers’ liability coverage. Spencer Minnich sminnich85@hotmail.com Vice President Peru Madison Iowa Sarah Minnich Travis Tuttle Signed
186 2021-02-24 14:35 Anonymous (not verified) 216.51.194.37 Estherville Aviation, Inc. 1672 425th Ave, Estherville, IA 51334 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-02-24 Paul Abrams Slaughter estavtn@yourstarnet.net Estherville Emmet Iowa Jordan Lampman Dwayne Hoss Signed (1) The corporation rejects the employers’ liability coverage. Paul Abrams Slaughter estavtn@yourstarnet.net President Estherville Emmet Iowa Jordan Lampman Dwayne Hoss Signed
298 2021-07-30 11:05 Anonymous (not verified) 165.225.60.212 Love Tap Racing LLC 1122 Sunset Ave, Kelley, IA 50134 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-07-30 Laura Love tiredemon@gmail.com Kelley Story IA Katie Frame Cody Jones Signed (1) The corporation rejects the employers’ liability coverage. Laura Love tiredemon@gmail.com Owner Ames Story IA Katie Frame Cody Jones Signed
410 2022-02-20 19:10 Anonymous (not verified) 173.27.233.68 A and W marble and tile Inc 207 Philip St. Des Moines, Iowa 50315 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-20 Wayne Yergy wyergy@gmail.com Des Moines Polk Iowa John Noga Angie Carter Signed (1) The corporation rejects the employers’ liability coverage. Wayne A Yergy wyergy@gmail.com Vice President Des Moines IA United States John Noga Angie Carter Signed
522 2022-07-27 21:58 Anonymous (not verified) 173.25.135.5 Kokemiller construction 5995 Martin drive I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-27 Jessie james kokemiller jkokemo3@gmail.com Pleasant Hill Polk Ia Jonathon Hays Demi Muchmore Signed (1) The corporation rejects the employers’ liability coverage. Jessie James kokemiller jkokemo3@gmail.com President Pleasant Hill Polk Ia Jonathon Hays Demi Muchmore Signed
985 2024-05-13 17:15 Anonymous (not verified) 94.188.207.225 Rail and Road Equipment Co 1797 G50 HWY. St. Charles, IA. 50240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-13 Jeffrey Pontier railandroad@myomnotel.com St Charles Warren IA Abbi Goering Travis Allen Signed (1) The corporation rejects the employers’ liability coverage. Jeffrey Pontier railandroad@myomnitel.com President St Charles Warren IA Abbi Goering Travis Allen Signed
634 2023-03-22 14:40 Anonymous (not verified) 94.188.205.167 Guardian Real Estate Inspection Services LLc 2623 Shady Lane Dr Norwalk, Iowa 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. 2023-03-22 Joseph D Nelson scott@imperialia.com West Des Moines Polk Iowa Pedro Antonio Steve Flynn Signed (1) The corporation rejects the employers’ liability coverage. Joseph Neslon Scott@imperialia.com Owner West Des Moines IA Iowa Steve Flynn Pedro Antonio Signed
746 2023-08-17 11:31 Anonymous (not verified) 94.188.207.225 NIEMEYER WELL AND PUMP INC 2735 GARFIELD AVE, HULL IA 51239 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-15 ELIJAH NIEMEYER PERSONALELINIEMEYER@GMAIL.COM HULL SIOUX IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The corporation rejects the employers’ liability coverage. ELIJAH NIEMEYER PERSONALELINIEMEYER@GMAIL.COM SELF HULL SIOUX IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
858 2024-01-18 08:24 Anonymous (not verified) 94.188.207.226 Custom Flooring LLC 7085 Bloomfield Road Lot 249 Des Moines, Iowa 50320 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-18 Jesus Vera jesusvera199027@icloud.com Des Moines Polk Iowa Natalia Vera Adriana de Anda Signed (1) The corporation rejects the employers’ liability coverage. Jesus Vera jesusvera199027@icloud.com Owner Des Moines Polk Iowa Natalia Vera Adriana de Anda Signed
90 2020-06-10 11:46 Anonymous (not verified) 173.28.7.32 DMG INSTALLATIONS INC 5534 NE 17TH ST #4 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-06-10 CLIFFORD LEE BAKER CLBAKER@MEDIACOMBB.NET ALTOONA POLK IOWA DAVID PAUL DUNLAP JASON DAVID MUSSO Signed (1) The corporation rejects the employers’ liability coverage. CLIFFORD LEE BAKER CLBAKER@MEDIACOMBB.NET PRESIDENT ALTOONA POLK IOWA JASON DAVID MUSSO DAVID PAUL DUNLAP Signed
202 2021-03-08 10:43 Anonymous (not verified) 151.147.196.21 Iowa Gold Distributing, Inc. 600 Iehl Street, Central City, IA 52214 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-02-10 Rebeccah Walters igdenv@aol.com Central City Linn Iowa William Walters Jennifer Leinen Signed (1) The corporation rejects the employers’ liability coverage. Rebeccah Walters igdenv@aol.com Secretary Central City Linn Iowa William Walters Jennifer Leinen Signed
314 2021-08-19 12:58 Anonymous (not verified) 173.26.33.84 CLINK FM, INC. 110 N. Maryville Street, Calmar, IA 52132 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-19 Jesse Y Goplen jessegoplen@gmail.com Oelwein Fayette IA Della Nehring Tim Nehring Signed (1) The corporation rejects the employers’ liability coverage. Kyana Taillon kyana@clink.fm Co-Founder/Vice-President Oelwein Fayette IA Della Nehring Tim Nehring Signed
426 2022-03-22 12:06 Anonymous (not verified) 69.54.105.130 Downing Development, Ltd. 13004 NW 44th St Polk City, IA 50226 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-22 Carolyn Suzanne Downing susiedowningdevelopment@gmail.com Polk City IA United States Geneva Aki Ross Amy Sue Romero Signed (1) The corporation rejects the employers’ liability coverage. Carolyn Suzanne Downing susiedowningdevelopment@gmail.com Secretary Polk City Polk County Iowa Geneva Aki Ross Amy Sue Romero Signed
538 2022-09-21 17:04 Anonymous (not verified) 174.198.67.151 Premiere Painting, LLC 865 NE Bobcat Dr I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-21 Scott McVay premierepainting515@gmail.com Waukee Dallas Iowa Christina Pham Robert Ferguson Signed (1) The corporation rejects the employers’ liability coverage. Scott McVay premierepainting515@gmail.com Owner Waukee Dallas Iowa Christina Pham Robert Ferguson Signed
650 2023-04-10 13:06 Anonymous (not verified) 94.188.205.168 Deep Cleaning Janitorial Inc 3131 33rd Ave SW Ceder Rapids IA 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-04-11 Paul Mwai deepcleaning0142@gmail.com Cedar Rapids IA United States Mary Ngotho John Johnson Signed (1) The corporation rejects the employers’ liability coverage. Ray Robertson deepcleaning0142@gmail.com Co-Owner Cedar Rapids Linn United States Shelley Robertson William Robertson Signed
762 2023-09-01 09:00 Anonymous (not verified) 94.188.207.226 Paradigm Group, LLC 3263 Cumming Road, Cumming, IA 50061 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-09-01 Hunter Fees iowatuckpointing@gmail.com Carlisle Warren Iowa Jered Holker Wes Duncan Signed (1) The corporation rejects the employers’ liability coverage. Ryan Shabino ryan@prdgmgroup.com Owner Cumming Madison Iowa Wes Duncan Jered Holker Signed
874 2024-01-29 14:30 Anonymous (not verified) 94.188.205.174 Proefco LLC 502 s Cadwell AVE I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-30 Kendy Melendrez kendydej@gmail.com Eagle Grove IA IA Kendy Melendrez Jaime Hernandez Signed (2) The corporation declines to reject the employers’ liability coverage. Kendy Melendrez kendydej@gmail.com owner Eagle Grove IA IA Kendy Melendrez Jaime Hernandez Signed
106 2020-07-27 12:12 Anonymous (not verified) 206.125.132.254 Pacos Roofing Inc 837 Lynkaylee Dr Waterloo, IA 50701 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-07-27 Blanca Garcia Pacosroofing@outlook.com Waterloo Black Hawk Iowa Kaitlin Schepers Sarah Whalen Signed (1) The corporation rejects the employers’ liability coverage. Blanca Garcia Pacosroofing@outlook.com Owner Waterloo Black Hawk Iowa Kaitlin Schepers Sarah Whalen Signed
218 2021-03-29 08:04 Anonymous (not verified) 173.18.193.51 Lee County Fair, Inc PO Box 179, Donnellson, 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 Matthew Wilson judy@fullenkampins.com Donnellson Lee Iowa Lindsey Lampe Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Matthew Wilson judy@fullenkampins.com Board Member Donnellson Lee Iowa l0 Judy Moeller Signed
330 2021-09-08 10:20 Anonymous (not verified) 206.80.128.71 H F Corporation 105 Oskaloosa St Pella, IA 50219 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-08 Nayan Patel super8pella@gmail.com Pella Marion Iowa Mark Chambers Jim Wessels Signed (1) The corporation rejects the employers’ liability coverage. Jeremy Rogstad jeremy@jeremyrogstad.com State Farm Agent Charles City Floyd Iowa Mark Chambers Jim Wessels Signed
442 2022-04-11 13:15 Anonymous (not verified) 75.162.175.12 Castro construction LLC 1712 carpenter av desmoines Iowa 50314 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-11 Carlos Alberto castro Alcántara castrodvxhd@gmail.com Estados Unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe padilla bonilla Signed (1) The corporation rejects the employers’ liability coverage. Carlos Alberto castro Alcántara castrodvxhd@gmail.com Owner Estados unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe Padilla Bonilla Signed
905 2024-02-28 11:47 Anonymous (not verified) 94.188.207.228 Monarca General Builders LLC 551 Martin Rd Waterloo Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-01 Antonio Serrato Sánchez assmsaeaj@icloud.com Waterloo Black Hawk Iowa Maria santos Juarez Adan Alvarez Signed (1) The corporation rejects the employers’ liability coverage. Antonio Serrato Sánchez assmsaeaj@icloud.com Presidente Waterloo Black Hawk Iowa Maria santos Juarez Adan Alvarez Signed