589 |
2023-01-16 10:18 |
Anonymous (not verified) |
174.130.20.253 |
HCS Trucking LLC |
403 Date St 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. |
2023-01-16 |
Jamie Hedstrom |
hedstromcrane@gmail.com |
Schleswig |
Crawford |
Iowa |
Noah Hedstrom |
Landa Hedstrom |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Jamie Hedstrom |
hedstromcrane@gmail.com |
owner |
Schleswig |
Crawford |
Iowa |
Noah Hedstrom |
Landa Hedstrom |
Signed |
533 |
2022-09-08 11:04 |
Anonymous (not verified) |
174.198.66.66 |
WCDEVINE LLC dba Five Star Painting of Cedar Falls |
6333 Leversee 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. |
2022-09-08 |
Wade Devine (owner) |
Wade.Devine@fivestarpainting.com |
Waterloo |
Blackhawk |
Iowa |
Brad Johnson |
Tom Wildeboer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Wade Devine |
Wade.Devine@fivestarpainting.com |
Owner/Same person |
Waterloo |
Blackhawk |
Iowa |
Brad Johnson |
Tom Wildeboer |
Signed |
538 |
2022-09-21 17:04 |
Anonymous (not verified) |
174.198.67.151 |
Premiere Painting, LLC |
865 NE Bobcat Dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-09-21 |
Scott McVay |
premierepainting515@gmail.com |
Waukee |
Dallas |
Iowa |
Christina Pham |
Robert Ferguson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott McVay |
premierepainting515@gmail.com |
Owner |
Waukee |
Dallas |
Iowa |
Christina Pham |
Robert Ferguson |
Signed |
356 |
2021-11-05 20:38 |
Anonymous (not verified) |
174.198.67.233 |
R.A. Snow Removals, Inc |
525 7th St. NW Altoona, IA 50009 |
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. |
2021-11-05 |
Robert Snow |
rasnowremovals.inc@gmail.com |
Altoona |
Polk |
Iowa |
Shannon Moses |
Jameson Snow |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Aaron Snow |
rasnowremovals.inc@gmail.com |
President |
Altoona |
Polk |
Iowa |
Shannon Moses |
Jameson Snow |
Signed |
510 |
2022-07-12 09:13 |
Anonymous (not verified) |
174.198.70.141 |
Premiere Painting, LLC |
865 NE Bobcat Dr Waukee, IA. 50263 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-07-12 |
Scott McVay |
scottkmcvay@live.com |
Waukee |
Dallas |
Iowa |
Robert Ferguson |
Christina Pham |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott McVay |
scottkmcvay@live.con |
Owner |
Waukee |
Dallas |
Iowa |
Robert Ferguson |
Christina Pham |
Signed |
551 |
2022-10-02 10:56 |
Anonymous (not verified) |
174.198.70.237 |
Des Moines Roofing Contractor |
2234 Highland St Des Moines, IA |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-10-02 |
Nancy Lopez |
nanoran3@gmail.com |
Des Moines |
Polk City |
IA |
Noe Ordaz |
Angie Florian |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nancy Lopez |
nanoran3@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Noe Ordaz |
Angie Florian |
Signed |
224 |
2021-03-29 11:26 |
Anonymous (not verified) |
174.198.71.64 |
Pro wash Dubuque inc |
1795 Atlantic 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. |
2021-03-28 |
Jordan John block |
prowashdubuque@gmail.com |
East Dubuque |
Jo Davis |
IL |
Abigail Ann Metcalf |
Dawn Marie block |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ludovissy insurance |
jeff@ludovissyandassociates.com |
He is my agent |
Dubuque |
Dubuque country |
IA |
Jordan John block |
Abigail Ann Metcalf |
Signed |
171 |
2021-01-26 15:07 |
Anonymous (not verified) |
174.198.73.28 |
R. A. Snow Removals, Inc |
525 7th 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. |
2021-01-26 |
Robert Aaron Snow |
rasnowremovals.inc@gmail.com |
Altoona |
Polk |
Iowa |
Shannon Keely Moses |
Jessy James Dentler |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Aaron Snow |
rasnowremovals.inc@gmail.com |
President |
Altoona |
Polk |
Iowa |
Shannon Keely Moses |
Jessy James Dentler |
Signed |
176 |
2021-02-03 15:02 |
Anonymous (not verified) |
174.198.90.166 |
Jesse's Embers LLC |
3301 Ingersoll Ave, Des Moines, IA, 50312 |
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. |
2021-02-03 |
Deena Edelstein |
dledelstein@hotmail.com |
Des Moines |
Polk |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Deena Edelstein |
dledelstein@hotmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
177 |
2021-02-03 15:07 |
Anonymous (not verified) |
174.198.90.166 |
Jesse's Embers LLC |
3301 Ingersoll Ave, Des Moines, IA, 50312 |
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. |
2021-02-03 |
Martin Scarpino |
martyscarpino@yahoo.com |
Des Moines |
Polk |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Martin Scarpino |
martyscarpino@yahoo.com |
Owner |
Des Moines |
IA |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
268 |
2021-05-25 10:03 |
Anonymous (not verified) |
174.198.97.100 |
Paradigm Construction, LLC |
960 Pelican Dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-25 |
Joshua Beougher |
jbooyah84@gmail.com |
Winterset |
Madison |
Iowa |
Ryan Shabino |
Jonathon Curtis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ryan Shabino |
ryan@prdgmconstruction.com |
Owner |
Polk City |
Polk |
Iowa |
Josh Beougher |
Jonathon Curtis |
Signed |
119 |
2020-09-28 10:43 |
Anonymous (not verified) |
174.213.149.6 |
Ddp construction |
1923 63rd st, des moines ,ia 50322 |
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. |
2020-09-28 |
Dustin a perry |
perrythedustin@gmail.com |
Urbandale |
Polk |
Iowa |
Lucas jackson |
Cody roth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Smith Kenyon insurance |
smithkenyon@yahoo.com |
Agent |
Urbandale |
Polk |
Ia |
Lucas jackson |
Cody roth |
Signed |
440 |
2022-03-29 20:05 |
Anonymous (not verified) |
174.215.228.20 |
Navarro construction |
2825 SE 14th St lot #6 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-29 |
Enrique Navarro |
enriquenavarro887@gmail.com |
Des Moines |
Polk |
IA |
Alondra Navarro |
René Navarro |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Enrique Navarro |
enriquenavarro884@gmail.com |
Owner |
Des moines |
Polk |
IA |
Alondra Navarro |
René Navarro |
Signed |
568 |
2022-11-15 08:23 |
Anonymous (not verified) |
174.215.243.6 |
Cesar rolando Acosta rivera |
2080 king ave apt 21 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. |
2022-11-15 |
Cesar rolando Acosta Rivera |
acostariveracesarrolando@gmail.com |
Des Moines Iowa |
Polk |
Iowa |
Juan acosta |
Antonio acosta |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cesar rolando Acosta Rivera |
acostariveracesarrolando@gmail.com |
Owner |
Des moines |
Polk |
Iowa |
Juan acosta |
Antonio acosta |
Signed |
569 |
2022-11-15 08:23 |
Anonymous (not verified) |
174.215.243.6 |
Cesar rolando Acosta rivera |
2080 king ave apt 21 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. |
2022-11-15 |
Cesar rolando Acosta Rivera |
acostariveracesarrolando@gmail.com |
Des Moines Iowa |
Polk |
Iowa |
Juan acosta |
Antonio acosta |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cesar rolando Acosta Rivera |
acostariveracesarrolando@gmail.com |
Owner |
Des moines |
Polk |
Iowa |
Juan acosta |
Antonio acosta |
Signed |
421 |
2022-03-07 17:14 |
Anonymous (not verified) |
174.215.244.140 |
MJ Kunkel Trucking, LLC |
403 N Ash 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. |
2022-03-07 |
Michael John Kunkel |
mjkunkeltrucks@gmail.com |
Marcus |
IA |
United States |
Adam Bartels |
Karlee Ohrt |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael John Kunkel |
mikekunkel0361@gmail.com |
Self |
Marcus |
IA |
United States |
Adam Bartels |
Karlee Ohrt |
Signed |
58 |
2020-04-14 08:32 |
Anonymous (not verified) |
174.217.17.57 |
Society of St Vincent de Paul, District Counsel Waterloo Iowa |
320 Broadway St PO Box 2727 Waterloo IA 50704 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-14 |
Rodney Crowe |
crorod@aol.com |
Waterloo |
Blackhawk |
Iowa |
George W Karnivk |
Glynis R Worthington |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph D Sobczyk |
joczyk@aol.com |
Corporate Treasurer |
Cdear Falls |
Blackhawk |
Iowa |
George W Karnick |
Glynis R Worthington |
Signed |
94 |
2020-07-02 08:19 |
Anonymous (not verified) |
174.217.21.87 |
James Subcontracting |
5212 South Union st. |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-02 |
James Lee Wardell |
jlw21479@gmail.com |
Des Moines |
IA |
United States |
Tammy Wardell |
Bobby Hoch |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Subcontracting |
jlw21479@gmail.com |
Owner |
Des Moines |
IA |
United States |
Tammy Wardell |
Bobby Hoch |
Signed |
139 |
2020-11-24 15:45 |
Anonymous (not verified) |
174.219.2.33 |
Dan Petersen Construction LLC |
1725 South 14th St, Polk City, IA 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-11-24 |
Daniel Petersen |
danpetersenconstruction@gmail.com |
Polk City |
Polk |
Iowa |
Erik Gramenz |
Jim McMurray |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Petersen |
danpetersenconstruction@gmail.com |
Owner |
Polk City |
Polk |
Iowa |
Erik Gramenz |
Jim McMurray |
Signed |
523 |
2022-07-29 10:25 |
Anonymous (not verified) |
174.235.192.89 |
Jayden leinen |
5176 ne 88th st altoona 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. |
2022-07-29 |
Jayden leinen |
jman.legend@outlook.com |
Altoona |
Polk |
Iowa |
Kaden Barton |
Noah Penn |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jayden Leinen |
jman.legend@outlook.con |
President |
Altoona |
Polk |
Iowa |
Kaden Barton |
Noah Penn |
Signed |
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 |
319 |
2021-08-24 10:19 |
Anonymous (not verified) |
174.243.114.142 |
Sabbatical Services LLC |
20732 Johnson St., Milo, IA 50166 |
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. |
2021-08-24 |
Bryce Gilbert |
bryce.ssllc@outlook.com |
Milo |
Warren |
Iowa |
Kathryn Gilbert |
Kolton Gilbert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bryce Gilbert |
bryce.ssllc@outlook.com |
President |
Milo |
Warren |
Iowa |
Kathryn Gilbert |
Kolton Gilbert |
Signed |
118 |
2020-09-15 14:32 |
Anonymous (not verified) |
174.243.115.133 |
Jurisdiction Approved Plumbing Corporation |
P.O. Box 343 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-09-15 |
Christian m Lavia |
eeejumble@gmail.com |
Urbandale |
Polk |
Iowa |
Tina m Heuckendorf |
Roslyn Heuckendorf |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christian m Lavia |
eeejumble@gmail.com |
Director |
Urbandale |
Polk |
IOWA |
Tina m Heuckendorf |
Roslyn Heukendorf |
Signed |
231 |
2021-04-11 12:19 |
Anonymous (not verified) |
174.243.115.140 |
Blaser Plumbing Inc |
28933 Sieverding Ridge Rd Bellevue IA 52031 |
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. |
2021-04-11 |
Michael Blaser |
bpi1999@hotmail.com |
Bellevue |
IA |
United States |
Joyce Langmeier |
Sylvester Langmeier |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Blaser |
bpi1999@hotmail.com |
Owner |
Bellevue |
IA |
United States |
Joyce Langmeier |
Sylvester Langmeier |
Signed |
429 |
2022-03-24 13:37 |
Anonymous (not verified) |
174.255.1.155 |
Franky's Construction |
1419 Acacia Dr NE, Cedar Rapids, IA 52402 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-24 |
Frank Ackley |
fackley1981@gmail.com |
Cedar Rapids |
Linn |
IA |
Rick Deneve |
Kailee Carstensen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Franky Ackley |
fackley1981@gmail.com |
Owner |
Cesar Rapids |
Linn |
IA |
Rick DeNeve |
Kailee Carstensen |
Signed |
269 |
2021-05-25 20:25 |
Anonymous (not verified) |
174.71.12.114 |
The Town and Country Aqua Club of Council Bluffs |
15444 Cherry Tree Lane Council Bluffs, Iowa 51503 |
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. |
2021-05-25 |
David Alan Bergman |
dbrgmn@gmail.com |
Council Bluffs |
Iowa |
United States |
Brett Ford |
Sean Dunphy |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Alan Bergman |
dbrgmn@gmail.com |
Board Vice President |
Council Bluffs |
Iowa |
United States |
Brett Ford |
Sean Dunphy |
Signed |
264 |
2021-05-18 22:36 |
Anonymous (not verified) |
174.71.14.68 |
Town and country Aqua Club |
22687 James Dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-18 |
Hope LaShea Diercks |
townandcountrycb@gmail.com |
Council bluffs |
Pottawattamie |
Iowa |
John James Diercks |
Keenan James Diercks |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Hope LaShea Diercks |
townandcountrycb@gmail.com |
Treasurer |
Council bluffs |
Pottawattamie |
Iowa |
John James Diercks |
Keenan James Diercks |
Signed |
586 |
2022-12-16 15:53 |
Anonymous (not verified) |
184.184.197.146 |
Halide Biologics |
330 Golfview Ave, Iowa City IA 52246 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-12-15 |
Daniel Infield |
danielinfield@gmil.com |
Bennington |
Douglas |
Nebraska |
Alexander Estell |
Jesse Herrera |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Infield |
danielinfield@gmail.com |
President |
Bennington |
NE |
United States |
Alexander Estell |
Jesse Herrera |
Signed |
578 |
2022-12-05 09:45 |
Anonymous (not verified) |
184.185.80.106 |
John A. Paul Consulting, LLC |
40962 Brothers Ave, Henderson, IA 51541 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-12-05 |
John A. Paul |
johnaddisonpaul1@gmail.com |
Henderson |
Mills County |
Iowa |
Paul Wilson |
Melanie Donegan |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John A. Paul |
johnaddisonpaul1@gmail.com |
President |
Henderson |
Mills County |
Iowa |
Paul Wilson |
Melanie Donegan |
Signed |
44 |
2020-03-09 10:51 |
Anonymous (not verified) |
184.63.116.185 |
STURCO BUILDERS |
24472 15TH AVE NEW VIRGINIA IA 50210 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-03-09 |
LANE WILLIAM STURTZ |
Sturcobuilders@live.com |
New virginia |
warren |
Iowa |
EMILY LAURA STURTZ |
JODI LEEANN GARNER |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LANE WILLIAM STURTZ |
Sturcobuilders@live.com |
OWNER |
NEW VIRGINIA |
WARREN |
IOWA |
EMILY LAURA STURTZ |
JODI LEEANN GARNER |
Signed |
384 |
2022-01-06 16:01 |
Anonymous (not verified) |
184.80.177.137 |
Top R Farms |
1199 Woodland Drive - Dyersville, IA 52040 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-06 |
Robert Fangmann |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
82 |
2020-05-18 15:16 |
Anonymous (not verified) |
184.80.177.137 |
Farmers Best Popcorn, LLC |
110 1st Street North, - Worthington, IA 52078 |
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. |
2020-05-18 |
Jon Ramaekers |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
self |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
541 |
2022-09-23 13:13 |
Anonymous (not verified) |
184.80.177.137 |
Tim & Lori Daly |
25430 New Vienna Rd - Farley, IA 52046 |
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. |
2022-09-23 |
Tim Daly |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
agent |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
103 |
2020-07-23 09:23 |
Anonymous (not verified) |
184.80.177.137 |
Jacob Reiff |
15738 N Cascade Rd - Peosta, IA 52068 |
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. |
2020-07-23 |
Jacob Reiff |
jheims@engish-insurance.com |
Peosta, |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
owner |
Peosta |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
108 |
2020-08-19 09:39 |
Anonymous (not verified) |
184.80.177.137 |
Michelle's Vocational Placement LLC |
2642 Farragut Pl., 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. |
2020-08-18 |
Tara Rommel |
jheims@engish-insurance.com |
Davenport |
Scott |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
115 |
2020-09-08 09:48 |
Anonymous (not verified) |
184.80.177.137 |
Beyond Builders LLC |
206 Culver Road NE, Hopkinton, IA 52237 |
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. |
2020-09-08 |
John Eiben |
ginger_bread_man@msn.com |
HOPKINTON |
Delaware |
IA |
Derrick Parsons |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John Eiben |
ginger_bread_man@msn.com |
Owner |
Hopkinton |
Delaware |
Iowa |
Derrick Parsons |
Derrick Parsons |
Signed |
129 |
2020-10-30 11:23 |
Anonymous (not verified) |
184.80.177.137 |
Haberdash Outfitters, Inc. |
109 1st Ave East - Dyersville, IA 52040 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-10-27 |
Jennifer Recker |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
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 |
144 |
2020-12-04 12:02 |
Anonymous (not verified) |
184.80.177.137 |
Arlen, LLC |
322 6th St SE - Dyersville, Iowa 52040 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-04 |
Dan Arlen |
jheims@english-insurance.com |
Dyersville |
IA |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joyce Heims |
joyce.heims1@gmail.com |
agent |
Dyersville |
IA |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
388 |
2022-01-11 13:58 |
Anonymous (not verified) |
184.80.177.137 |
Demmer Construction |
203 Michigan Ave - Farley, IA 52046 |
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. |
2021-12-21 |
Charlie Demmer |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jenny Osburn |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
389 |
2022-01-11 14:02 |
Anonymous (not verified) |
184.80.177.137 |
Demmer Construction |
203 Michigan Ave - Farley, IA 52046 |
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. |
2021-05-12 |
Charlie Demmer |
jheims@english-insurance.com |
Farley |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jenny Osburn |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
396 |
2022-02-01 10:03 |
Anonymous (not verified) |
184.80.177.137 |
LKB Holdings, LLC |
P.O. box 313 - Monona, Ia 52159 |
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. |
2022-01-29 |
Kandi Gillitzer |
jheims@english-insurance.com |
Monoa |
Clayton |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
self |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
515 |
2022-07-19 10:06 |
Anonymous (not verified) |
184.80.177.137 |
Mom Clean, LLC |
4 East 3rd Street - Earlville, IA 52041 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-07-18 |
Morgan Lahr |
dparsons@english-insurance.com |
Dyersville |
Delaware |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
self |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
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 |
455 |
2022-04-27 14:04 |
Anonymous (not verified) |
184.80.177.137 |
Classic Custom Cabinets, Inc |
31931 Bries Drive , Dyersville, IA 52040 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-04-27 |
Mike Then |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
448 |
2022-04-19 15:15 |
Anonymous (not verified) |
184.80.177.137 |
Andrew Lemke DBA: TAP Fabrication |
27214 218th Street, Earlville, IA 52041 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-04-08 |
Andrew Lemke |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
413 |
2022-02-23 16:31 |
Anonymous (not verified) |
184.80.177.137 |
T-Rex Hospitality LLC, DBA FUSE |
120 Twin Steeples Circle, Dyersville 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. |
2022-02-23 |
Tara Rahe |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
87 |
2020-06-09 14:49 |
Anonymous (not verified) |
185.169.109.170 |
Sweeney Builders Inc |
511 8th 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. |
2020-06-09 |
Michael Lee Sweeney |
mike@sweeneybuilders.com |
Waukon |
Allamakee |
Iowa |
Shawna Sweeney |
Jean Gavin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Shawna Sweeney |
shawna@sweeneybuilders.com |
Vice President |
Waukon |
Allamakee |
IA |
Mike Sweeney |
Jean Gavin |
Signed |
585 |
2022-12-15 20:32 |
Anonymous (not verified) |
192.110.196.132 |
Maywood Enterprises, Inc. |
28345 Highway 52, Bellevue, IA 52031 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-12-15 |
Ann L Wachtel |
annw@financepro123.com |
Bellevue |
Jackson |
Iowa |
Katie Laban |
Jeffrey Laban |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ann L Wachtel |
annw@financepro123.com |
President |
Bellevue |
Jackson |
IA |
Katie Laban |
Jeffrey Laban |
Signed |
461 |
2022-05-02 11:08 |
Anonymous (not verified) |
192.119.212.86 |
Iceberg Enterprises LLC |
101 E. 1st street Arthur IA 51431 |
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 |
Jesse Bergman |
jk_montana@yahoo.com |
arthur |
Iowa |
United States |
Maren Smith |
Darren Smith |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Katherine Bergman |
jk_montana@yahoo.com |
Owner |
Arthur |
IOWA |
United States |
Susan Bergman |
Jesse Bergman |
Signed |