263 |
2021-05-06 15:18 |
Anonymous (not verified) |
174.243.113.232 |
Agronomic Solutions |
908 E Dubuque St Quasqueton IA 52326 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-06 |
Brandy Hodges |
mapping@agsolutionsinc.net |
Coon Rapids |
IA |
United States |
Jacki Sloss |
Don Sloss |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Friday Insurance |
doug.miller@fridayinsurance.net |
agent |
Osceola |
Clarke |
IA |
Jacki Sloss |
Don Sloss |
Signed |
375 |
2021-12-23 12:23 |
Anonymous (not verified) |
66.230.245.47 |
W. R. Elliot & Associates, Ltd. |
3306 Brook Hollow Dr, Asbury, 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. |
2021-12-23 |
William R. Elliot |
bill@wreassoc.com |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L. Spalla |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William R. Elliot |
bill@wreassoc.com |
President |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L Spalla |
Signed |
487 |
2022-06-02 08:36 |
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. |
2022-05-25 |
Jacob Denning |
judy@fullenkampins.com |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jacob Denning |
judy@fullenkampins.com |
Board Member |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
599 |
2023-02-13 12:14 |
Anonymous (not verified) |
94.188.207.227 |
Christian Gilbert |
3174 HWY F48 W. Newton, IA 50208 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-02-13 |
Christian Gilbert |
christian.gilbert14@gmail.com |
Newton |
Jasper |
Iowa |
Marcus Thompson |
Crystal Ward |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christian Gilbert |
christian.gilbert14@gmail.com |
self |
Newton |
Jasper |
Iowa |
Marcus Thompson |
Crystal Ward |
Signed |
711 |
2023-07-24 12:04 |
Anonymous (not verified) |
94.188.205.176 |
HAIGH & ESPE LIMITED |
1198 GRAND AVE, MARION, IA 52302 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-07-24 |
LYNN M. HAIGH |
ADAMSTILEANDSTONE@GMAIL.COM |
Cedar Rapids |
Linn |
Iowa |
DAVID REIBSAMEN |
STACEY ROGERS |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LYNN M. HAIGH |
ADAMSTILEANDSTONE@GMAIL.COM |
CORP. SECRETARY |
CEDAR RAPIDS |
LINN |
IOWA |
DAVID REIBSAMEN |
STACEY ROGERS |
Signed |
823 |
2023-11-20 14:04 |
Anonymous (not verified) |
94.188.205.169 |
CDNE, Inc. |
311 E. Alta Vistta 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. |
2023-11-20 |
Craig Allen Payne |
Craig.Payne@indianhills.edu |
Ottumwa |
Wapello |
Iowa |
Erin Elizabeth Payne |
Nathan Thomas Payne |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Desirae Lynn Payne |
desip845@gmail.com |
Spouse |
Ottumwa |
Wapello |
Iowa |
Erin Elizabeth Payne |
Nathan Thomas Payne |
Signed |
902 |
2024-02-26 11:37 |
Anonymous (not verified) |
94.188.207.228 |
roorda dairy llc |
5128 460th st |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-22 |
scott roorda |
scottyroorda@hotmail.com |
granville |
obrien county |
iowa |
lance roorda |
larry roorda |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
kyle blankers |
kyle@veinsurance.com |
member |
5128 460th st |
obrien county |
iowa |
lance roorda |
larry roorda |
Signed |
55 |
2020-04-06 16:25 |
Anonymous (not verified) |
74.221.44.37 |
Steele Land & Livestock, Inc |
1040 190th St, Anita, IA 50020 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-06 |
Doug Steele |
dsteele@midlands.net |
Anita |
Adair |
Iowa |
Sheryl Leonard |
Cheryl Ellis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Doug Steele |
dsteele@midlands.net |
President |
Anita |
Adair |
Iowa |
Sheryl Leonard |
Cheryl Ellis |
Signed |
167 |
2021-01-26 11:56 |
Anonymous (not verified) |
74.84.91.178 |
Shea Real Estate LLC |
135 Devon Drive, Dubuque, IA 52001 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-17 |
Lucas Kahl |
shearealestatellc@gmail.com |
Dubuque |
Dubuque |
Iowa |
Gabe Drewelow |
Brenda Lewis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lucas Kahl |
shearealestatellc@gmail.com |
President |
Dubuque |
Dubuque |
Iowa |
Gabe Drewelow |
Brenda Lewis |
Signed |
279 |
2021-06-23 10:41 |
Anonymous (not verified) |
184.80.177.137 |
AA Breeders |
P.O. Box 470 - Epworth, IA 52045 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-06-22 |
Justin Curtis |
jheims@english-insurance.com |
Epworth |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
AA Breeders - Justin Curtis |
jheims@english-insurance.com |
self |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
391 |
2022-01-26 16:08 |
Anonymous (not verified) |
207.199.212.86 |
Geerts Plumbing and Heating Inc. |
913 N Linn Ave, New Hampton, IA 50659 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-07-07 |
Adam S Geerts |
lacy@cioia.com |
New Hampton |
Chickasaw |
Iowa |
Lacy Carolan |
Maddi Moorman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam S Geerts |
lacy@cioia.com |
Owner |
New Hampton |
Chickasaw |
Iowa |
Lacy Carolan |
Maddi Moorman |
Signed |
503 |
2022-06-30 17:15 |
Anonymous (not verified) |
209.180.36.109 |
Sani Enterprise |
101 Ashworth Rd |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-30 |
Nexhat Krasniqi |
nexhat_80@hotmail.com |
WEST DES MOINES |
polk |
Iowa |
Sandro Tadic |
Andy Swanson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sandro Tadic |
sanienterprise14@gmail.com |
Owner |
Urbandale |
Polk |
Iowa |
Sandro Tadic |
Andy Swanson |
Signed |
615 |
2023-02-28 08:15 |
Anonymous (not verified) |
94.188.207.224 |
River City Transport |
201 Lezlie 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. |
2023-02-28 |
Christopher Ryan Brewer |
chris@rivercitylogistics.net |
Peosta |
Dubuque County |
Iowa |
Brian Brewer |
Nicholas Lester |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chris Brewer |
chris@rivercitylogistics.net |
Owner |
Peosta |
Iowa |
United States |
Brian Brewer |
Nicholas Lester |
Signed |
727 |
2023-08-02 18:25 |
Anonymous (not verified) |
94.188.205.176 |
Furever Friends Rescue of Appanoose, Inc |
19507 Hwy 2, Centerville, Iowa 52544 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-02 |
Krystal Fowler |
krystalfowler@gmail.com |
Cincinnati |
Appanoose |
Iowa |
Jennifer Appler |
Kimberly Stonehouse |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Krystal Fowler |
krystalfowler@gmail.com |
Treasurer |
Cincinnati |
Appanoose |
Iowa |
Jennifer Appler |
Kim Stonehouse |
Signed |
839 |
2023-12-18 16:12 |
Anonymous (not verified) |
94.188.207.227 |
515 Painting llc |
po box 157 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-18 |
Marvin S Parker JR |
stvpkr@gmail.com |
berwick |
polk |
iowa |
Christopher Eldridge |
Dillon Parker |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Marvin parker |
stvpkr@gmail.com |
owner |
berwick |
Polk |
Iowa |
Christopher Eldridge |
Dillon Parker |
Signed |
918 |
2024-03-11 14:29 |
Anonymous (not verified) |
94.188.207.224 |
DeJear Inc. |
3220 SW 34th Street, Des Moines, Iowa 50321 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-11 |
Marvin L. DeJear Jr |
marvin.dejear@gmail.com |
Des Moines |
Polk |
Iowa |
Rory Robson |
Geoff Matlock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Marvin L. DeJear Jr |
dejear@dejearcorporation.com |
Chief Administrative Officer |
Des Moines |
Polk |
Iowa |
Rory Robson |
Geoff Matlock |
Signed |
71 |
2020-04-27 16:23 |
Anonymous (not verified) |
140.82.166.162 |
Loss Control Specialist Inc |
1409 Jackson Woods Ct NW Cedar Rapids, IA 52409 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-28 |
James Riggert |
jim@losscontrolspecialist.com |
Cedar Rapids |
Linn |
Iowa |
Megan Thomas |
Jessica Droppert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Riggert |
jim@losscontrolspecialist.com |
President |
Cedar Rapids |
Linn |
Iowa |
Megan Thomas |
Jessica Droppert |
Signed |
404 |
2022-02-13 12:50 |
Anonymous (not verified) |
217.180.228.177 |
Premier Property Group LLC |
8805 Chambery Blvd Ste 300 #217 Johnston, IA 50131 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-02-13 |
Cade Montgomery |
ppgiowallc@gmail.com |
Johnston |
Polk |
Iowa |
Cailey Montgomery |
Sara Saylor |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cade Montgomery |
ppgiowallc@gmail.com |
Owner |
Johnston |
Polk |
Iowa |
Cailey Montgomery |
Sara Saylor |
Signed |
516 |
2022-07-19 15:43 |
Anonymous (not verified) |
66.207.21.24 |
Frank Iliff |
1424 B Houser Street |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-07-22 |
Frank Iliff |
rtmuscatine@gmail.com |
Muscatine |
IA |
United States |
Dewayne Hopkins |
James R. Bell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Frank Iliff |
rtmuscatine@gmail.com |
Executive Director |
Muscatine |
IA |
United States |
Dewayne Hopkins |
James R. Bell |
Signed |
628 |
2023-03-21 12:07 |
Anonymous (not verified) |
94.188.207.226 |
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. |
2023-03-21 |
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 |
John Johnson |
Mary Ngotho |
Signed |
740 |
2023-08-14 10:25 |
Anonymous (not verified) |
94.188.205.167 |
Absolute Mud Jacking Inc |
5038 Brittany Ct Bettendorf Iowa 52722 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-12 |
Paul Pelzer |
pelzer830@gmail.com |
Bettendorf |
IA |
United States |
Brett Lewandowski |
Phil Schaefer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Pelzer |
pelzer830@gmail.com |
Owner |
Bettendorf |
IA |
United States |
Brett Lewandowski |
Phil Schaefer |
Signed |
852 |
2024-01-14 15:48 |
Anonymous (not verified) |
94.188.205.166 |
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. |
2024-01-14 |
Travis D Crouch |
trvscrouch@gmail.com |
Des Moines |
Iowa |
United States |
Jodi Essex |
Linda K Renze |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Travis D Crouch |
trvscrouch@gmail.com |
President |
Des Moines |
IA |
United States |
Jodi Essex |
Linda K Renze |
Signed |
931 |
2024-03-21 20:54 |
Anonymous (not verified) |
94.188.207.228 |
Cnr drywall llc |
410 w 6th st muscatine Iowa 52761 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-21 |
Jair Romo |
cnrdrywall@gmail.com |
Muscatine |
Muscatine |
Iowa |
Jordy tenorio |
Emmanuel Nunez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cnr drywall |
cnrdrywall@gmail.com |
Owner |
Muscatine |
Muscatine |
Ia |
Jordy tenorio |
Emmanuel Nunez |
Signed |
84 |
2020-06-01 16:31 |
Anonymous (not verified) |
173.29.126.110 |
TruthPoint Media LLC |
1945 Andrews Drive, Pleasant Hill, IA 50327 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-06-01 |
Robert Lee Moore |
robb@truthpointmedia.com |
Pleasant Hill |
Polk |
Iowa |
Self, Sole Proprietor and LLC Member, TruthPoint Media LLC |
Self, Sole Proprietor and LLC Member, TruthPoint Media LLC |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert L Moore |
robb@truthpointmedia.com |
Self |
Pleasant Hill |
Polk |
Iowa |
Self, Sole Proprietor and LLC Member, TruthPoint Media LLC |
Self, Sole Proprietor and LLC Member, TruthPoint Media LLC |
Signed |
196 |
2021-03-03 11:11 |
Anonymous (not verified) |
173.31.147.225 |
TLI INVESTMENTS INC |
1712 368TH 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. |
2021-02-15 |
LESLI IVERSON |
TBYRDLES@YAHOO.COM |
ESTHERVILLE |
EMMET |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LESLI IVERSON |
TBYRDLES@YAHOO.COM |
PRESIDENT |
ESTHERVILLE |
EMMET |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
308 |
2021-08-13 15:23 |
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 |
Tom Weidner |
mmatlock@thedanaco.com |
Des Moines |
Polk |
IA |
Megan Matlock |
Ron Goodman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tom Weidner |
mmatlock@thedanaco.com |
Owner |
Des Moines |
Polk |
IA |
Megan Matlock |
Ron Goodman |
Signed |
420 |
2022-03-04 13:58 |
Anonymous (not verified) |
209.180.36.109 |
Sani Enterprise LLC |
101 Ashworth Rd |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-04 |
Mustafa Keserovic |
MustafaKeserovic@gmail.com |
Ankeny |
Pokl |
Iowa |
Sandro Tadic |
Andrew Swanson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sandro Tadic |
sanienterprise14@gmail.com |
Owner |
WEST DES MOINES |
Iowa |
United States |
Sandro Tadic |
Andrew swanson |
Signed |
532 |
2022-09-07 12:42 |
Anonymous (not verified) |
217.180.226.147 |
Practical Farmers of Iowa |
1615 Golden Aspen Dr., Suite 101, Ames, IA 50010 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-09-07 |
Jonathan Bakehouse |
jon@mapleedgefarm.com |
Hastings |
Mills |
Iowa |
Jeanne-Marie Bakehouse |
DeWayne Kroledge |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sally Worley |
sally@practicalfarmers.org |
Executive Director |
Ames |
Story |
United States |
Jeann-Marie Bakehouse |
DeWayne Kroledge |
Signed |
644 |
2023-03-31 08:47 |
Anonymous (not verified) |
94.188.205.175 |
HDEZ, LLC |
7500 Bloomfield Rd, Lot 91, Des Moines, IA 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-31 |
Antonio Rosales |
tonyh873@gmail.com |
Des Moines |
Polk |
Iowa |
Ronald Barton |
Scott Grimm |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Antonio Rosales |
tonyh873@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Ronald Barton |
Scott Grimm |
Signed |
756 |
2023-08-28 09:10 |
Anonymous (not verified) |
94.188.205.177 |
J.R. Stelzer Co. |
5850 Russell Dr Ste 1, Lincoln, NE 68507 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-07-01 |
William James Stelzer |
bill@jrstelzer.com |
Lincoln |
Nebraska |
United States |
Michael G Stelzer |
Marcia Brouillette |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William James Stelzer |
bill@jrstelzer.com |
Officer |
Lincoln |
Lancaster |
NE |
Michael G. Stelzer |
Marcia Brouillette |
Signed |
868 |
2024-01-25 14:08 |
Anonymous (not verified) |
94.188.207.229 |
NeX Level Moving, LLC |
5634 Deerwood St. SW, Cedar Rapids, IA, 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-25 |
Trevor McCauley |
jhawktm@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Bridget |
Camp |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Trevor McCauley |
jhawktm@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Bridget Camp |
Trevor McCauley |
Signed |
947 |
2024-04-05 09:55 |
Anonymous (not verified) |
94.188.207.228 |
Foley Contracting LLC |
6730 Double Eagle Dr., Davenport, IA 52804 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-05 |
Samuel Nathan Foley |
foleycontracting@gmail.com |
Davenport |
Scott |
IA |
Gaynelle Warren |
Evon McNeal |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Samuel Foley |
foleycontracting@gmail.com |
Owner |
Davenport |
Scott |
IA |
Gaynelle Warren |
Evon McNeal |
Signed |
100 |
2020-07-14 19:08 |
Anonymous (not verified) |
208.90.8.234 |
Humboldt County Agricultural |
311 N 6th Ave, P.O. Box 391, Humboldt, IA 50548 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-18 |
Jeff Haselhuhn |
gjhaselhuhn@gmail.com |
Humboldt |
Humboldt |
IA |
Marva Anderson |
Jeff Halverson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Marva Anderson |
info@humboldtcountyfair.com |
Business Manager |
Humboldt |
81 |
81 |
Marva Anderson |
Jeff Halverson |
Signed |
212 |
2021-03-25 09:26 |
Anonymous (not verified) |
204.155.61.217 |
Mark Burger |
3993 Shoreline Dr, Robbinsdale, MN 55422 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-03 |
Mark Burger |
markb@hailmayday.com |
Robbinsdale |
hennepin |
MN |
DocuSign |
Ashley Kraft |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mark Burger |
markb@hailmayday.com |
Owner |
Robbinsdale |
Robbinsdale |
MN |
DocuSign |
Ashley Kraft |
Signed |
324 |
2021-08-31 09:19 |
Anonymous (not verified) |
76.84.58.43 |
Dave's Lawn Care |
716 4th Ave Nebraska City NE68410 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-01 |
David Wilberger |
daveslawncare00@gmail.com |
NEBRASKA CITY |
NE |
United States |
Linda Bowers |
Thomas Hume |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Wilberger |
daveslawncare00@gmail.com |
owner |
Nebraska City |
Otoe |
NE |
Linda Bowers |
Thomas Hume |
Signed |
436 |
2022-03-29 11:07 |
Anonymous (not verified) |
184.80.177.137 |
Adam Sheppard |
22194 260th St - Delhi, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-24 |
Adam Sheppard |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam Sheppard |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
548 |
2022-09-29 09:06 |
Anonymous (not verified) |
208.126.212.128 |
City of Leland |
316 Walnut St., PO Box 127, Leland, IA 50453 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-09-29 |
Rex Johnson |
rexr@wctatel.net |
Leland |
Winnebago |
Iowa |
Roger Torkelson |
Kelly Bendickson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dawn Arispe |
leland@wctatel.net |
City of Leland City Clerk |
Leland |
Winnebago |
Iowa |
Roger Torkelson |
Kelly Bendickson |
Signed |
660 |
2023-04-26 07:56 |
Anonymous (not verified) |
94.188.207.227 |
Darrin Hearn DBA GoodCauseMinis |
445 Onyx Ave Marion IA 52302 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-26 |
Darrin Hearn |
goodcauseminis@gmail.com |
Marion |
IA |
United States |
Darrin Hearn |
Darrin Hearn |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Darrin Hearn |
goodcauseminis@gmail.com |
owner |
Marion |
IA |
United States |
Darrin Hearn |
Darrin Hearn |
Signed |
772 |
2023-09-18 12:52 |
Anonymous (not verified) |
94.188.207.224 |
Wallenburg Trucking LLC |
911 8th Street SW |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-09-18 |
Heath Ryan Wallenburg |
heathwallenburg@gmail.com |
Rock Valley |
IA |
United States |
Dustin Van Beek |
Lucas Van Engen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Deric Hill |
d.hill@joemorten.com |
Insurance |
Sioux City NE |
Dakota County |
Nebraska |
Dustin Van Beek |
Lucas Van Engen |
Signed |
884 |
2024-02-05 11:31 |
Anonymous (not verified) |
94.188.205.175 |
NeX Level Moving LLC |
5634 Deerwood ST SW cedar rapids iowa 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-05 |
Robert Sanders |
Sandersrob101300@gmail.com |
Cedar Rapids |
Linn |
Iowa |
dallas haul |
johntay buck |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Sanders |
Sandersrob101300@gmail.com |
self |
cedar rapids |
linn |
iowa |
dallas haul |
Johntay buck |
Signed |
963 |
2024-04-29 17:42 |
Anonymous (not verified) |
94.188.207.227 |
Total Construction Inc |
4607 S Ridge Rd Sioux City IA 51106 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-29 |
Daniel J Jennett II |
dj_jennett@hotmail.com |
Sioux City |
Woobury |
IA |
Julia L Lesko |
Olivia J Lesko |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel J Jennett II |
dj_jennett@hotmail.com |
President |
Sioux City |
Woodbury |
IA |
Julia L Lesko |
Olivia J Lesko |
Signed |
116 |
2020-09-11 11:42 |
Anonymous (not verified) |
69.57.22.68 |
Brush and Weed Control Specialists, Inc. |
1108 230th Street - Algona, IA 50511 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-09-11 |
Ruth Jean Lindgren |
bwcontrol@netamumail.com |
Algona |
Kossuth |
Iowa |
James Black |
Katie Melvin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Donald H Reffer |
bwcontrol@netamumail.com |
President and General Manager |
Algona |
Kossuth |
Iowa |
James Black |
Katie Melvin |
Signed |
228 |
2021-04-05 13:06 |
Anonymous (not verified) |
173.18.193.51 |
Houghton Cedar Township Fire Department |
1135 140th Avenue, Salem, Iowa 52649 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-03 |
Brad Vandenberg |
judy@fullenkampins.com |
Donnellson |
Lee |
Iowa |
Judy Moeller |
Shelby Green |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Vandenberg |
judy@fullenkampins.com |
Board Member |
Salem |
Lee |
Iowa |
Judy Moeller |
Shelby Green |
Signed |
340 |
2021-10-01 15:44 |
Anonymous (not verified) |
3.217.29.203 |
Tracy Countryman |
745 Robert Drive Moville, IA 51039 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-30 |
Tracy Countryman |
Tracycountryman@ymail.com |
Moville |
Woodbury |
Iowa |
Deborah Clark |
Jane Ashley |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tracy Countryman |
Tracycountryman@ymail.com |
President |
Moville |
Woodbury |
Iowa |
Deborah Clark |
Jane Ashley |
Signed |
452 |
2022-04-22 16:06 |
Anonymous (not verified) |
75.63.172.134 |
Tempus Builders, Inc. |
4331 Valley Ridge 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. |
2022-04-22 |
Scott Cooper |
scott@tempusbuilders.com |
Dallas |
TX |
United States |
Phil Sheumaker |
Cristen Cooper |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott Cooper |
scott@tempusbuilders.com |
President |
Dallas |
TX |
United States |
James Buckley |
Phil Sheumaker |
Signed |
564 |
2022-11-12 13:05 |
Anonymous (not verified) |
152.117.104.212 |
ArborSharp Tree Care LLC |
125 South Russell Ave Ames IA 50010 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-11-12 |
Jonathan Michael Ostermann |
arborsharptc@gmail.com |
Ames |
IA |
IA |
Ben Wyatt |
Marc McClanahan |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jonathan Ostermann |
arborsharptc@gmail.com |
owner |
Ames |
story |
IA |
Ben Wyatt |
Marc McClanahan |
Signed |
676 |
2023-05-26 16:16 |
Anonymous (not verified) |
94.188.207.230 |
Miller Lawn Care LLC |
1323 S Hwy 52 Guttenberg IA 52052 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-05-26 |
Steven Miller |
nicole@cioia.com |
Guttenberg |
Clayton |
IA |
Nicole Parker |
Jerry J Rochford |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Steven Miller |
nicole@cioia.com |
owner-self |
Guttenberg |
Clayton |
IA |
Nicole Parker |
Jerry J Rochford |
Signed |
788 |
2023-10-16 07:32 |
Anonymous (not verified) |
94.188.207.225 |
Aurora Aesthetics and Functional Medicine LLC |
713 1st Ave NW |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-04 |
Stephanie Friess |
Aurorafunctionalmed@gmail.com |
Mount Vernon |
IA |
United States |
Michael Friess |
Meagan Friess |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Friess |
mfriess1985@gmail.com |
business manager |
Mount Vernon |
Iowa |
IA |
Michael Friess |
Meagan Friess |
Signed |
979 |
2024-05-10 14:40 |
Anonymous (not verified) |
94.188.207.224 |
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. |
2024-05-10 |
Hunter Brown |
bbpropertymaintenance1@gmail.com |
Ankeny |
Polk County |
Iowa |
Landon Brown |
Ryan Rose |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kelsey Prince |
office@prdgmgroup.com |
Office Manager |
Cumming |
Madison |
Iowa |
Kyle McGinn |
Robin McGinn |
Signed |
20 |
2019-12-30 09:39 |
Anonymous (not verified) |
207.191.194.182 |
LA Trends Addict Inc |
1200 N CENTER POINT RD |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-10-07 |
Laura Frey |
fcrentals1@gmail.com |
HIAWATHA |
Linn |
IA |
Traci Lyons |
Allie DeVore |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Laura Frey |
fcrentals1@gmail.com |
Owner |
HIAWATHA |
Linn |
IA |
Traci Lyons |
Allie DeVore |
Signed |