37 |
2020-02-06 15:49 |
Anonymous (not verified) |
100.42.95.100 |
Matthew Saboe |
2075 330th St, Spencer IA 51301 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-06 |
Matthew Saboe |
galmgirl@gmail.com |
Spencer |
Clay |
IA |
Laura Ashley Tauscher |
Diane Kimball |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Matthew Saboe |
galmgirl@gmail.com |
Owner |
Spencer |
Clay |
IA |
Laura Ashley Tauscher |
Diane Kimball |
Signed |
152 |
2021-01-04 12:08 |
Anonymous (not verified) |
104.129.206.120 |
Schleswig Transfer Inc |
216 Valley View Dr, Schleswig, IA 51461 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-11-30 |
Wade Miller |
t.uhl3@joemorten.com |
Schleswig |
Crawford |
Iowa |
Tamara Uhl |
Amy Meseck |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Wade Miller |
t.uhl3@joemorten.com |
President |
Schleswig |
Crawford |
IA |
Tamara Uhl |
Amy Meseck |
Signed |
288 |
2021-07-22 16:17 |
Anonymous (not verified) |
104.166.243.230 |
Renewal By Anderson |
517 railroad ave. West Des Moines |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-07-22 |
Cameron Thede |
camthede22@gmail.com |
Windsor Heights |
Polk |
Iowa |
Mac Laven |
sdofkn |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Renewal By Andersen |
james@rbadesmoines.com |
Subcontractor |
West Des Moines |
Polk |
IA |
Mac Laven |
lsdfkn lsadnf |
Signed |
471 |
2022-05-13 10:08 |
Anonymous (not verified) |
104.166.245.37 |
Juan Ramiro Rivas Perez |
6211 SW 5th Street. Des Moines IA 50315 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-02 |
Juan Ramiro Rivas Perez |
cecyperezv1982@icloud.com |
Des Moines |
Polk |
Iowa |
Carmen Perez |
Oscar Ramirez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Juan Ramiro Rivas Perez |
cecyperezv1982@icloud.com |
Secretary |
Des Moines |
Polk |
Iowa |
Carmen Perez |
Oscar Ramirez |
Signed |
201 |
2021-03-04 10:04 |
Anonymous (not verified) |
104.193.30.26 |
JDS TRANSFER, INC. |
22327 60TH ST, OELWEIN, IA 50662 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-04 |
AMANDA S. KOESTER |
STAMP210@HOTMAIL.COM |
OELWEIN |
FAYETTE |
IOWA |
KACIE DERR |
LEANNA STAMP |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
JACOB D STAMP |
STAMP210@HOTMAIL.COM |
PRESIDENT |
OELWEIN |
FAYETTE |
IOWA |
KACIE DERR |
LEANNA STAMP |
Signed |
126 |
2020-10-28 14:31 |
Anonymous (not verified) |
104.207.25.44 |
Little Bison Daycare Center |
404 2nd St. NW Buffalo Center, IA 50424 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-10-28 |
Cody Tyler Wirtjes |
cody@afschem.com |
Buffalo Center |
Winnebago |
Iowa |
Michael James Perkins |
Garrett Alan Asmus |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cody Tyler Wirtjes |
cody@afschem.com |
Board President |
Buffalo Center |
Winnebago |
Iowa |
Michael James Perkins |
Garrett Alan Asmus |
Signed |
127 |
2020-10-28 14:42 |
Anonymous (not verified) |
104.207.31.201 |
Little Bison Childcar Center, Inc. |
404 2nd St NW |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-10-28 |
Travis Brass |
travis.brass@rakestatesavingsbank.com |
Lakota |
Kossuth |
Iowa |
Tami Jacobson |
Carol Winter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Travis Brass |
travis.brass@rakestatesavingsbank.com |
Treasurer |
Lakota |
Kossuth |
Iowa |
Tami Jacobson |
Carol Winter |
Signed |
597 |
2023-02-06 08:11 |
Anonymous (not verified) |
107.121.104.18 |
Household Nanny |
1357 Woolridge Dr., Coralville, IA 52241 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-02-06 |
Giselle Marie Statz |
Gisellestatz@gmail.com |
Coralville |
IA |
United States |
Jeffrey Peterson |
Casey Edwards |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Giselle Marie Statz |
gisellestatz@gmail.com |
Owner |
CORALVILLE |
Johnson |
Iowa |
Jeffrey Peterson |
Casey Edwards |
Signed |
596 |
2023-02-06 08:08 |
Anonymous (not verified) |
107.121.104.18 |
Household Nanny |
1357 Woolridge Dr., Coralville, IA 52241 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-02-06 |
Stephen John Statz |
sstatz32@gmail.com |
Coralville |
IA |
United States |
Jeffrey Peterson |
Casey Edwards |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Stephen John Statz |
sstatz32@gmail.com |
Owner |
Coralville |
IA |
United States |
Jeffrey Peterson |
Casey Edwards |
Signed |
456 |
2022-04-29 08:14 |
Anonymous (not verified) |
107.126.24.57 |
Thatcher Auto Center INC |
406 S West Ave. Baxter, IA 50028 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-01 |
Matthew Lee Wells |
Praynostop@msn.com |
Des Moines |
Polk |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rick Thatcher |
rickswrecks@gmail.com |
President |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
459 |
2022-04-29 08:49 |
Anonymous (not verified) |
107.126.24.57 |
Thatcher Auto Center INC |
406 S West ave Baxter. IA 50028 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-02-15 |
David Kirkman |
kirkcola@gmail.com |
Newton |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rick Thatcher |
rickswrecks@gmail.com |
President |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
457 |
2022-04-29 08:21 |
Anonymous (not verified) |
107.126.24.57 |
Thatcher Auto Center INC |
406 S West ave Baxter, IA 50028 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-01 |
Nathan Doubek |
thatcherautocenter@gmail.com |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rick Thatcher |
rickswrecks@gmail.com |
President |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
458 |
2022-04-29 08:26 |
Anonymous (not verified) |
107.126.24.57 |
Thatcher Auto Center INC |
406 S West ave Baxter Iowa 50028 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-01 |
Richard Thatcher |
rickswrecks@gmail.com |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nathan Doubek |
thatcherautocenter@gmail.com |
Vice President |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
114 |
2020-09-04 13:11 |
Anonymous (not verified) |
107.182.207.0 |
KEITH N SLYTER |
PO 2632 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-09-04 |
KEITH N SLYTER |
KNSCONST@GMAIL.COM |
DAVENPORT |
25|IA |
iowa |
KEITH N SLYTER |
KEITH N SLYTER |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
KEITH N SLYTER |
KNSCONST@GMAIL.COM |
owner |
DAVENPORT |
25|IA |
iowa |
KEITH N SLYTER |
KEITH N SLYTER |
Signed |
75 |
2020-04-29 11:07 |
Anonymous (not verified) |
107.77.206.22 |
ACR Construction, Inc |
7330 NW 21 St. Ankeny, IA 50023 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-29 |
Andre Sean Drost |
andre.drost@acr-construction-inc.com |
Ankeny |
Polk |
IA |
Heidi Smith |
Jeff Smith |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Candace Drost |
acrdrost@hotmail.com |
President |
Ankeny |
Polk |
IA |
Heidi Smith |
Jeff Smith |
Signed |
566 |
2022-11-14 17:50 |
Anonymous (not verified) |
107.77.206.66 |
JGR Carpentry |
1305 N 6th St Apt. 11 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-11-14 |
Josiah Grant Robinson |
grantyboy87@yahoo.com |
Indianola |
Warren |
Iowa |
Timothy William Robinson |
Austin Micheal Ross |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Josiah Grant Robinson |
grantyboy87@yahoo.com |
Corporation President |
Indianola |
Warren |
Iowa |
Timothy William Robinson |
Austin Micheal Ross |
Signed |
249 |
2021-05-03 09:29 |
Anonymous (not verified) |
107.77.206.82 |
Cassatt drywall |
3235 woodland dr leclaire IA |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-02 |
James Jansen |
james.jansen23@yahoo.com |
Davenport |
Scott |
IA |
Kara kelting |
Jake harris |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Steve cassatt |
cassattdrywall@gmail.com |
Owner |
Leclaire |
Scott |
IA |
Kara kelting |
Jake harris |
Signed |
508 |
2022-07-04 18:49 |
Anonymous (not verified) |
107.77.210.228 |
RM Construction, Rafael Marquez DBA |
6520 SE 5th ST, Apt 4, Des Moines, IA 50315 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-07-04 |
Rafael Marquez |
marquezrafael1@outlook.com |
6520 SE 5th ST, Apt 4, Des Moines IA, 50315 |
Polk |
IOWA |
Richard Yanez |
Jesus Perez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rafael Marquez |
marquezrafael1@outlook.com |
owner |
Des Moines |
Polk |
IOWA |
Richard Yanez |
Jesus Perez |
Signed |
83 |
2020-05-20 12:34 |
Anonymous (not verified) |
108.171.131.188 |
North Iowa Custom Seamless Guttering, Inc |
PO Box 512, 1300 2nd Ave S, Clear Lake, Iowa 50428 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-05-20 |
Keith E Main |
keithmaincsg@hotmail.com |
Clear Lake |
Cerro Gordo |
Iowa |
Lloyd L Heinselman |
Diane K Harrington |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Keith E Main |
keithmaincsg@hotmail.com |
President |
Clear Lake |
Cerro Gordo |
Iowa |
Lloyd L Heinselman |
Diane K Harrington |
Signed |
34 |
2020-01-16 13:10 |
Anonymous (not verified) |
108.171.132.188 |
B & C Lawn Care Inc |
P.O. Box 55, Boone, IA 50036 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-01-01 |
Caleb Elliott |
onethird4599@gmail.com |
Boone |
Boone |
Iowa |
Katie Frame |
Jessica Carroll |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Caleb Elliott |
onethird4599@gmail.com |
Owner |
Boone |
Boone |
IOWA |
Katie Frame |
Jessica Carroll |
Signed |
32 |
2020-01-14 10:33 |
Anonymous (not verified) |
108.171.132.189 |
B & C Lawn Care Inc |
P.O. Box 55, Boone, IA 50036 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-01-01 |
Travis Garrett |
onethird4599@gmail.com |
Boone |
Boone |
Iowa |
Katie Frame |
Jessica Carroll |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Travis Garrett |
onethird4599@gmail.com |
Owner |
Boone |
Boone |
IOWA |
Katie Frame |
Jessica Carroll |
Signed |
174 |
2021-01-29 12:08 |
Anonymous (not verified) |
108.174.118.195 |
Tempered Solutions HVAC LLC |
897 Old Corvallis Road |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-29 |
Zachery Wiediger |
temperedsolutionshvac@gmail.com |
Corvallis |
Montana |
United States |
Julie R. Ostrenga |
Douglas M. Ostrenga |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Zachery Wiediger |
temperedsolutionshvac@gmail.com |
Self |
Corvallis |
Montana |
United States |
Douglas M. Ostrenga |
Julie R. Ostrenga |
Signed |
161 |
2021-01-14 19:19 |
Anonymous (not verified) |
108.174.118.195 |
Four Seasons HVAC LLC |
3165 Four Seasons Drive, Stevensville, MT 59870 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-14 |
Douglas Michael Ostrenga |
doug@fourseasonshvac.com |
Stevensville |
Ravalli |
MT |
Zachery Donald Wiediger |
Thomas Maximillian Liedtka |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Julie Ruthanne Ostrenga |
julie@fourseasonshvac.com |
Member Manager |
Stevensville |
Ravalli |
MT |
Zachery Donald Wiediger |
Thomas Maximillian Liedtka |
Signed |
559 |
2022-10-24 15:14 |
Anonymous (not verified) |
108.178.192.251 |
LogicBox, Inc. |
2381 Highway 169, Winterset, IA 50273 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-10-24 |
Jeremy Goemaat |
jeremy.goemaat@gmail.com |
Winterset |
Madison |
Iowa |
Janelle Goemaat |
Gunnar Goemaat |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeremy Goemaat |
jeremy.goemaat@gmail.com |
CEO/Owner |
Winterset |
Madison |
Iowa |
Janelle Goemaat |
Gunnar Goemaat |
Signed |
353 |
2021-11-04 11:41 |
Anonymous (not verified) |
108.58.173.242 |
ASTL Moving And Storage Inc |
9530 FM 2920 #227 Tomball TX 77375 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-11-04 |
Peter Allen III |
astlmoving@yahoo.com |
Tomball |
Harris |
TX |
Peggi Makofka |
Yoel Taran |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Peter Allen III |
astlmoving@yahoo.com |
owner |
Tomball |
Harris |
TX |
Peggi Makofka |
Yoel Taran |
Signed |
403 |
2022-02-09 14:14 |
Anonymous (not verified) |
108.59.100.21 |
T Js Fencing Inc |
461 Hwy 76, Harpers Ferry IA 52146 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-13 |
Travis Johanningmeier |
tjfence@acegroup.cc |
Harpers Ferry |
Allamakee |
Iowa |
Jessica Kruse |
Jane M Regan |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Travis Johanningmeier |
tjfence@acegroup.cc |
President |
Harpers Ferry |
Allamakee |
Iowa |
Jessica Kruse |
Jane M Regan |
Signed |
480 |
2022-05-30 11:37 |
Anonymous (not verified) |
134.215.6.237 |
Access Property Management Corp DBA Wine & Spirits |
510 E Carrington Ln, Appleton, WI 54913 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-30 |
Lisa M Ricklefs |
lisarick19@yahoo.com |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferek |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Thomas Ricklefs |
tjrick@yahoo.com |
President |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferak |
Signed |
481 |
2022-05-30 11:42 |
Anonymous (not verified) |
134.215.6.237 |
Access Property Management Corp DBA Wine & Spirits |
510 E Carrington Ln, Appleton, WI 54913 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-30 |
Thomas J Ricklefs |
tjrick@yahoo.com |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferek |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa M Ricklefs |
lisarick19@yahoo.com |
VP |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferek |
Signed |
57 |
2020-04-10 11:14 |
Anonymous (not verified) |
136.34.78.83 |
KALONA SALES BARN, INC. |
191 9TH STREET; KALONA, IA 52247 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-07 |
DEVIN MULLET |
LMULLET@KALONASALESBARN.COM |
KALONA |
WASHINGTON |
IOWA |
ALANA MULLET |
ROCHELLE MULLET |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
DEVIN MULLET |
LMULLET@KALONASALESBARN.COM |
OWNER |
KALONA |
WASHINGTON |
IOWA |
ALANA MULLET |
ROCHELLE MULLET |
Signed |
56 |
2020-04-10 11:12 |
Anonymous (not verified) |
136.34.78.83 |
KALONA SALES BARN, INC. |
121 9TH ST; KALONA, IA 52247 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-06 |
LAVAUGHN MULLET |
LMULLET@KALONASALESBARN.COM |
KALONA |
WASHINGTON |
IOWA |
ALANA MULLET |
ROCHELLE MULLET |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LAVAUGHN MULLET |
LMULLET@KALONASALESBARN.COM |
OWNER |
KALONA |
WASHINGTON |
IOWA |
ALANA MULLET |
ROCHELLE MULLET |
Signed |
71 |
2020-04-27 16:23 |
Anonymous (not verified) |
140.82.166.162 |
Loss Control Specialist Inc |
1409 Jackson Woods Ct NW Cedar Rapids, IA 52409 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-28 |
James Riggert |
jim@losscontrolspecialist.com |
Cedar Rapids |
Linn |
Iowa |
Megan Thomas |
Jessica Droppert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Riggert |
jim@losscontrolspecialist.com |
President |
Cedar Rapids |
Linn |
Iowa |
Megan Thomas |
Jessica Droppert |
Signed |
72 |
2020-04-27 16:24 |
Anonymous (not verified) |
140.82.166.162 |
Loss Control Specialist Inc |
1409 Jackson Woods Ct NW Cedar Rapids, IA 52409 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-28 |
Pamala Riggert |
jim@losscontrolspecialist.com |
Cedar Rapids |
Linn |
Iowa |
Megan Thomas |
Jessica Droppert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Pamala Riggert |
jim@losscontrolspecialist.com |
Secretary |
Cedar Rapids |
Linn |
Iowa |
Megan Thomas |
Jessica Droppert |
Signed |
333 |
2021-09-14 14:53 |
Anonymous (not verified) |
147.0.156.50 |
O'Danny Boy Builders, Inc. |
7512 S. County Line Rd., Suite #4, Burr Ridge, IL 60527 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-14 |
Daniel Flanagan |
jflanagan@odannyboybuilders.com |
LaGrange |
Cook |
Illinois |
John Flanagan |
Mark Hayes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John Flanagan |
Jflanagan@odannyboybuilders.com |
Executive |
Western Springs |
Cook |
IL |
Ben Weed |
Mark Hayes |
Signed |
204 |
2021-03-08 10:43 |
Anonymous (not verified) |
151.147.196.21 |
Iowa Gold Distributing, Inc. |
600 Iehl Street, Central City, IA 52214 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2021-02-10 |
Brad Coates |
igdenv@aol.com |
Central City |
Linn |
Iowa |
William Walters |
Jennifer Leinen |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Brad Coates |
igdenv@aol.com |
Director |
Central City |
Linn |
Iowa |
William Walters |
Jennifer Leinen |
Signed |
203 |
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 |
William R. Walters |
igdenv@aol.com |
Central City |
Linn |
Iowa |
Jennifer Leinen |
Robert L. Hammerberg |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William R. Walters |
igdenv@aol.com |
President |
Central City |
Linn |
Iowa |
Jennifer Leinen |
Robert L. Hammerberg |
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 |
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 |
252 |
2021-05-04 13:47 |
Anonymous (not verified) |
159.242.43.24 |
J. Fox Distributing, Inc |
3801 Pierce Street, Sioux City, IA 51104 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-04 |
Joseph Fox |
huskerjoe12@gmail.com |
Sioux City |
Woodbury |
IA |
Jenny McIntyre |
Alex Meier |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph Fox |
huskerjoe12@gmail.com |
President |
Sioux City |
Woodbury |
IA |
Jenny McIntyre |
Alex Meier |
Signed |
397 |
2022-02-01 10:30 |
Anonymous (not verified) |
159.242.43.24 |
Providence Casework |
PO Box 205 Rockwell, IA 50469 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-01 |
Neal Keeling |
office@procaseworks.com |
Rockwell |
Cerro Gordo |
Iowa |
Josh Olson |
John Moran |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Neal Keeling |
office@procaseworks.com |
Owner |
Rockwell |
Cerro Gordo |
Iowa |
Josh Olson |
John Moran |
Signed |
251 |
2021-05-04 13:39 |
Anonymous (not verified) |
159.242.43.24 |
Parrott Distributing, Inc |
1429 16th Ave SE, Lemars, IA 51031 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-04 |
Jason Parrott |
jlparrott@premieronline.net |
Lemars |
Plymouth |
IA |
Jenny McIntyre |
Josh Olson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jason Parrott |
jlparrott@premieronline.net |
President |
Lemars |
Plymouth |
IA |
Jenny McIntyre |
Josh Olson |
Signed |
117 |
2020-09-11 11:54 |
Anonymous (not verified) |
162.218.1.22 |
american business resource corporation |
4600 American Parkway Suite #301 Madison, WI 53718 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-09-11 |
Michelle Szabrowicz |
mszabrowicz@abrjobs.com |
Madison |
Dane |
Wisconsin |
Patricia Haggerty |
Britney Mollet |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michelle Szabrowicz |
mszabrowicz@abrjobs.com |
CFO |
Madison |
Dane |
Wisconsin |
Patricia Haggerty |
Britney Mollet |
Signed |
390 |
2022-01-20 11:06 |
Anonymous (not verified) |
162.246.237.102 |
High Pointe Construction |
903 Summerset pl Indianola iowa 50125 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-19 |
Andrey Shabak |
shabakandre@gmail.com |
indianola |
warren |
Iowa |
Inna zayets |
bob |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andrey shabak |
shabakandre@gmail.com |
owner |
indianola |
warren |
ia |
inna zayets |
bob |
Signed |
125 |
2020-10-26 16:33 |
Anonymous (not verified) |
162.253.44.212 |
Gutter Filter Specialists Inc |
1805 Red Fox Way 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. |
2020-10-26 |
Richard L Mellor |
rickmellor88@gmail.com |
Marion |
Linn |
IA |
Katie Luehrsmann |
Melissa Lown |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Richard L Mellor |
rickmellor88@gmail.com |
President |
Marion |
Linn |
IA |
Katie Luehrsmann |
Melissa Lown |
Signed |
519 |
2022-07-22 13:55 |
Anonymous (not verified) |
162.253.44.28 |
Seeger Truck Trailer Repair, Inc. |
1125 66th AVE SW, Cedar Rapids IA 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-08-01 |
Eldora Seegers |
royalwsilverII@gmail.com |
Cedar Rapids |
Linn |
Iowa |
John Seegers |
Julie Jones |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Eldora Seergers |
royalwsilverII@gmail.com |
Officer |
Cedar Rapids |
Linn |
Iowa |
John Seegers |
Julie Jones |
Signed |
553 |
2022-10-03 15:32 |
Anonymous (not verified) |
165.206.254.105 |
Ski Mechanical Services |
729 Bell Ave. Des Moines, IA 50315 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-10-03 |
Terry Wave Konchalski |
skiwave79@gmail.com |
Des Moines |
Polk |
Iowa |
Melissa Kerr |
Charlie Ruperto |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Terry Wave Konchalski |
skiwave79@gmail.com |
Owner/President |
Des Moines |
Polk |
Iowa |
Melissa Kerr |
Charlie Ruperto |
Signed |
358 |
2021-11-15 09:39 |
Anonymous (not verified) |
165.225.57.41 |
Jerry Steward Trucking Inc. |
319 W. 7th Street, Janesville, IA 50647 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-22 |
Jerry Steward Sr. |
cedarfalls.oil@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jerry Steward Jr. |
cedarfalls.oil@gmail.com |
Vice-President |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
359 |
2021-11-15 09:43 |
Anonymous (not verified) |
165.225.57.41 |
Jerry Steward Trucking Inc |
319 W. 7th Street, Janesville, IA 50647 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-22 |
Jerry Steward Jr. |
cedarfalls.oil@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jerry Steward Sr. |
cedarfalls.oil@gmail.com |
President |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
360 |
2021-11-15 09:47 |
Anonymous (not verified) |
165.225.57.41 |
Jerry Steward Trucking Inc |
319 W. 7th Street, Janesville, IA 50647 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-22 |
Ruth Steward |
cedarfalls.oil@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jerry Steward Sr. |
cedarfalls.oil@gmail.com |
President |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
297 |
2021-07-30 11:05 |
Anonymous (not verified) |
165.225.60.212 |
Love Tap Racing LLC |
1122 Sunset Ave, Kelley, IA 50134 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-07-30 |
Timothy Love |
tiredemon@gmail.com |
Kelley |
Story |
IA |
Katie Frame |
Cody Jones |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Timothy Love |
tiredemon@gmail.com |
Owner |
Ames |
Story |
IA |
Katie Frame |
Cody Jones |
Signed |
298 |
2021-07-30 11:05 |
Anonymous (not verified) |
165.225.60.212 |
Love Tap Racing LLC |
1122 Sunset Ave, Kelley, IA 50134 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-07-30 |
Laura Love |
tiredemon@gmail.com |
Kelley |
Story |
IA |
Katie Frame |
Cody Jones |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Laura Love |
tiredemon@gmail.com |
Owner |
Ames |
Story |
IA |
Katie Frame |
Cody Jones |
Signed |