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Rejection of Workers' Compensation or Employers' Liability Coverage

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# Submitted User IP address Name of Corporation: Address of Corporation Home Office: Statement 1 Agreement: Statement 2 Agreement: Statement 3 Agreement: Statement Agreement: Check Either Alternative (1) or (2): Date: Full Name of Individual: Email: City of Residence: County of Residence: State of Residence: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Agreement: Alternative Selection: Full Name of Authorized Agent: Email of Authorized Agent: Relationship to Corporation of Authorized Agent: City of Residence: County of Residence: State: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Indication:
580 2022-12-09 11:20 Anonymous (not verified) 74.84.79.78 Aaron Alley 101 Teale St. Davis City, IA 50065 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 Aaron Alley alleyre@hotmail.com Davis City Decatur Iowa Michael O'Conner Ron Rand Signed (1) The corporation rejects the employers’ liability coverage. Aaron Alley alleyre@hotmail.com owner Davis City Decatur Iowa Michael O'Conner Ron Rand Signed
729 2023-08-04 07:39 Anonymous (not verified) 94.188.207.228 Barrel Head Winery Inc 9995 Laudeville Road, Dubuque, IA 52003 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-03 Aaron Fuhreck sales@barrelheadiowa.com Dubuque Dubuque Iowa Derrick Parsons Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Aaron Fuhreck sales@barrelheadiowa.com Owner Dubuque Dubuque Iowa Derrick Parsons Derrick Parsons Signed
365 2021-11-18 11:48 Anonymous (not verified) 64.5.67.201 C & H Body Repair Inc. 707 Lincoln Ave SE, Orange City, IA 51041 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. 2021-11-12 Aaron Huizenga ciui@orangecitycomm.net Orange City Sioux Iowa Daryl Beltman Lori Mars Signed (1) The corporation rejects the employers’ liability coverage. Aaron Huizenga ciui@orangecitycomm.net President Orange City Sioux Iowa Daryl Beltman Lori Mars Signed
529 2022-09-01 13:53 Anonymous (not verified) 72.131.73.148 Sozo Companies, Inc. 23751 Hoover Road, Warren MI 48089 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. 2022-09-01 Aaron Rasty arasty@sozocompanies.com Austin Travis Texas Robert Davis Paul Huth Signed (1) The corporation rejects the employers’ liability coverage. Aaron Rasty arasty@sozocompanies.com President Austin Travis Texas Robert Davis Paul Huth Signed
395 2022-01-31 15:49 Anonymous (not verified) 75.89.77.218 Mind Body Soul 22, Inc. 101 South St. Delhi, IA 52223 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. 2022-01-31 Abby Paige DeGroot abby.whittenbaugh@gmail.com Delhi Deleware Iowa Kaes Christian DeGroot Michael David Whittenbaugh Signed (1) The corporation rejects the employers’ liability coverage. Abby Paige DeGroot abby@mbs22.com President Delhi Deleware Iowa Kaes Christian DeGroot Michael David Whittenbaugh Signed
675 2023-05-24 07:55 Anonymous (not verified) 94.188.207.223 Sierra Roofing 401 W 15th Street West Liberty, IA 52776 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-24 Abraham Granjeno Sierra sierraroofing@gmail.com West Liberty Muscatine Iowa Cody Thorpe Claudia Venable Signed (1) The corporation rejects the employers’ liability coverage. Abraham Granjeno Sierra sierraroofing@gmail.com Owner/Self West Liberty Muscatine Iowa Cody Thorpe Claudia Venable Signed
893 2024-02-22 10:29 Anonymous (not verified) 94.188.207.226 Sierra Roofing 401 W 15th Street West Liberty, IA 52776 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-22 Abraham Granjeno Sierra absierra89@gmail.com West Liberty Muscatine Iowa Claudia Venable Dan Saunders Signed (1) The corporation rejects the employers’ liability coverage. Abraham Granjeno Sierra absierra89@gmail.com Owner/Self West Liberty Muscatine Iowa Claudia Venable Dan Saunders Signed
826 2023-11-22 08:04 Anonymous (not verified) 94.188.207.226 Sabuydee Corporation 617 Davis Ave. / Corning, IA 50841 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-22 Adam Grundman adamgrundman@gmail.com Corning Adams Iowa Carol Penglase MIchael Grundman Signed (1) The corporation rejects the employers’ liability coverage. Adam Grundman adamgrundman@gmail.com President Corning Iowa United States Carol Penglase Michael Grundman Signed
121 2020-10-01 09:40 Anonymous (not verified) 50.82.176.77 Kinion Towing Inc. 100 Industrial Park Drive, Clarence, IA 52216 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. 2020-09-30 Adam Kinion kinionas@yahoo.com Tipton Cedar Iowa Michael Blake Jeffrey Case Signed (1) The corporation rejects the employers’ liability coverage. Adam Kinion kinionas@yahoo.com Vice President Tipton Cedar Iowa Michael Blake Jeffrey Case Signed
829 2023-11-27 08:59 Anonymous (not verified) 94.188.207.224 Adam Ruess Masonry 206.w Elm st I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-27 Adam Ruess ruess33@gmail.com Lone Tree IA United States Adam Ruess Adam Ruess Signed (1) The corporation rejects the employers’ liability coverage. Adam Ruess ruess33@gmail.com Owner Lone Tree IA United States Adam Ruess Adam Ruess Signed
391 2022-01-26 16:08 Anonymous (not verified) 207.199.212.86 Geerts Plumbing and Heating Inc. 913 N Linn Ave, New Hampton, IA 50659 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-07-07 Adam S Geerts lacy@cioia.com New Hampton Chickasaw Iowa Lacy Carolan Maddi Moorman Signed (1) The corporation rejects the employers’ liability coverage. Adam S Geerts lacy@cioia.com Owner New Hampton Chickasaw Iowa Lacy Carolan Maddi Moorman Signed
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
505 2022-06-30 17:20 Anonymous (not verified) 209.180.36.109 Sani Enterprise 101 Ashworth Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-30 Admir Dogic adoydogic@gmail.com Urbandale polk iowa Sandro Tadic Andy Swanson Signed (2) The corporation declines to reject the employers’ liability coverage. Sandro Tadic sanienterprise14@gmail.com Owner Urbandale polk iowa Sandro Tadic Andy Swanson Signed
247 2021-04-27 09:35 Anonymous (not verified) 207.191.206.210 United windows and siding 4080 1st Avenue NE, Cedar Rapids Iowa 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. (2) I decline to reject the employer’s liability coverage. 2021-04-27 Adrian Sanchez adrian@unitedwindowsandsiding.com Aurora CO United States Megan Bierley Ginger Berens Signed (2) The corporation declines to reject the employers’ liability coverage. Adrian Sanchez adrian@unitedwindowsandsiding.com Owner Aurora Jeffereson CO Megan Bierley Ginger Berens Signed
416 2022-02-25 08:15 Anonymous (not verified) 70.100.125.106 Coachlight Condominium Owners Association 714 14th Ave N, Fort Dodge, IA 50501 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. 2022-02-25 Alan Wooters shirise@wtcta.net Fort Dodge Webster IA Randy Ranthum Paul Templemeyer Signed (1) The corporation rejects the employers’ liability coverage. Alan Wooters shirise@wtcta.net President Fort Dodge Webster IA Jackie Jacobs Paula Templemeyer Signed
863 2024-01-23 13:59 Anonymous (not verified) 94.188.205.176 United Marble & Tile, Inc. 915 8th Street, #201, 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. 2024-01-24 Albert James Gotta jim@umtile.com Slater Boone IA Antonina M Gotta MARY KATE RUSSELL Signed (1) The corporation rejects the employers’ liability coverage. Albert James Gotta jim@umtile.com President Sole Share Holder Boone IA IA Antonina M Gotta Antonina M Gotta Signed
357 2021-11-10 11:32 Anonymous (not verified) 207.45.82.37 Green and Shine Services. INC 210 Ne 41st ST APT 203 Ankeny, Iowa 50021 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2021-11-10 Alex Adanel Lopez Redondo greenandshineservices@gmail.com Ankeny polk Iowa Marta Casado Giselle Roa Casado Signed (2) The corporation declines to reject the employers’ liability coverage. Alex ADANEL Lopez Redondo greenandshineservices@gmail.com owner Ankeny polk Iowa Marta Casado Giselle Roa Casado Signed
557 2022-10-17 09:23 Anonymous (not verified) 67.22.198.94 Baker Irrigation Inc. 2621 310th St. Rock Valley, IA 51247 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. 2022-10-17 Alex DeJager alex@bakerirrigationia.com Rock Valley Sioux Iowa Jesse Niemeyer Herlan DeJager Signed (1) The corporation rejects the employers’ liability coverage. Alex DeJager alex@bakerirrigationia.com Co-Owner Rock Valley Sioux Iowa Jesse Niemeyer Herlan DeJager Signed
779 2023-10-04 07:14 Anonymous (not verified) 94.188.207.225 CanD Homes, LLC 1147 Leitha Ter, Waverly, IA 50677 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-04 Alexander Eckard-Lewis alex.lewis@candhomes.com Waverly Bremer IA Connor Eustice Victor Sanders Signed (1) The corporation rejects the employers’ liability coverage. Alexander Eckard-Lewis alex.lewis@candhomes.com Vice President Waverly Bremer IA Connor Eustice Victor Sanders Signed
242 2021-04-21 13:27 Anonymous (not verified) 198.14.211.149 Centerville Greenhouses 418 N. 5th Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-21 Alexander Joseph Lind alex@centervillegreenhouses.com Centerville IA United States John Douglas Hurley Dennis James Peters Signed (1) The corporation rejects the employers’ liability coverage. Peter Michael Lind peter@centervillegreenhouses.com President Centerville IA United States John Douglas Hurley Dennis James Peters Signed
777 2023-10-02 08:50 Anonymous (not verified) 94.188.205.176 Alexandria Munro 7020 Forest Drive, Johnston, IA 50131 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-02 Alexandria Munro armunro17@gmail.com Johnston Polk Iowa John Goodhue Miranda Cyr Signed (1) The corporation rejects the employers’ liability coverage. Alexandria Munro armunro17@gmail.com Owner Johnston Polk Iowa John Goodhue Miranda Cyr Signed
750 2023-08-20 16:41 Anonymous (not verified) 94.188.207.229 Wonderfully Made LLC 2003 Downing Ave Waterloo IA 50701 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-20 Alexis Lise Martinez victorandleximartinez@gmail.com Waterloo Black Hawk IA Trey Patterson Lauren Shaff Signed (1) The corporation rejects the employers’ liability coverage. Alexis Lise Martinez victorandleximartinez@gmail.com Owner Waterloo Black Hawk IA Trey Patterson Lauren Shaff Signed
798 2023-10-20 10:54 Anonymous (not verified) 94.188.205.177 Connerley Construction Inc 5915 4Th St. SW Cedar Rapids, Iowa 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-20 Allen Connerley betterrentalsbyconnerley@aol.com CEDAR RAPIDS Linn Iowa Nika Mefford Duane Anderson Signed (1) The corporation rejects the employers’ liability coverage. Connerley Construction Inc Connerleyconstruction@gmail.com Owner Cedar Rapids Linn IA Nika Mefford Duane Anderson Signed
366 2021-11-23 12:20 Anonymous (not verified) 173.19.234.191 Brezina Homes, Inc 9008 NW 73rd Place, Johnston, IA 50131 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-11-23 Allen J. Brezina a.brezina@mchsi.com Johnston Polk Iowa Christopher Winterboer Melissa Winterboer Signed (1) The corporation rejects the employers’ liability coverage. Allen J. Brezina a.brezina@mchsi.com President Johnston Polk Iowa Christopher Winterboer Melissa Winterboer 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
200 2021-03-03 17:33 Anonymous (not verified) 172.58.84.30 Amee Ann Pepperson 1536 1/2 W Locust I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-03 Amee Ann Pepperson amee0818@yahoo.com Davenport Scott Iowa Philip Gerald Hoxsey Michael Wayne Underdahl Signed (1) The corporation rejects the employers’ liability coverage. Amee A Pepperson amee0818@yahoo.com Self Davenport Scott Iowa Michael Wayne Underdahl Philip Gerald Hoxsey Signed
338 2021-09-22 10:34 Anonymous (not verified) 216.81.153.249 APS LLC 904 Lake Avenue 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. 2021-09-22 Amrit Singh amritaust1@gmail.com Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Amrit Singh amritaust1@gmail.com Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
150 2020-12-31 15:00 Anonymous (not verified) 216.81.153.249 S&A Holdings LLC 115 N 2nd Street, Fort Dodge, IA 50501 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. 2020-12-21 Amritpal Singh amritaust1@gmail.com Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Amritpal Singh amritaust1@gmail.com Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
24 2020-01-02 09:12 Anonymous (not verified) 207.191.194.182 Waukee CabinetWorks LLC 70 SE Laurel St, 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. 2019-12-23 Amy Balm chris.rappe@waukeecabinetworks.com Waukee Dallas Iowa Chris Andrews Dave Creighton Sr Signed (1) The corporation rejects the employers’ liability coverage. Chris Rappe chris.rappe@waukeecabinetworks.com Operations Manager Waukee Dallas IA Chris Andrews Dave Creighton SR 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
949 2024-04-05 20:16 Anonymous (not verified) 94.188.207.223 Viramontes Quality Lawncare LLC. 3029 E Washington Ave Des Moines,Iowa 50317 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-04-05 Andres Viramontes Barron a.viramontes1989@gmail.com Des Moines Iowa United States Clayton Garrison Gloria Cardenas Signed (1) The corporation rejects the employers’ liability coverage. Andres Viramontes a.viramontes1989@gmail.com owner Des Moines Iowa United States Clayton Garrison Gloria Cardenas Signed
832 2023-12-07 09:57 Anonymous (not verified) 94.188.207.226 Andrew Garberson 400 SW 42nd Street, 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. 2023-12-07 Andrew Garberson andrew.garberson@gmail.com Des Moines Polk IA Jeanette Harris Emily Feriz Signed (1) The corporation rejects the employers’ liability coverage. Andrew Garberson andrew.garberson@gmail.com Owner Des Moines Polk IA Jeanette Harris Emily Feriz Signed
227 2021-04-02 09:58 Anonymous (not verified) 207.177.7.191 GOETTSCH DISPATCH INC 200 MAIN ST GALVA, IA 51020 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. 2021-03-15 ANDREW GOETTSCH andygoettsch@gmail.com Galva Ida Iowa Kristy Dewey Terri Ullrich Signed (1) The corporation rejects the employers’ liability coverage. Andrew Goettsch andygoettsch@gmail.com President Galva Ida Iowa Kristy Dewey Terri Ullrich Signed
941 2024-04-03 10:26 Anonymous (not verified) 94.188.207.223 Andrew Renna 407 19th st spirit lake Iowa 51369 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-04-03 Andrew John Renna drewrenna86@gmail.com Spirit lake Dickinson Iowa Brianna Lene Nicholas Omang Signed (1) The corporation rejects the employers’ liability coverage. Andrew Renna drewrenna86@gmail.com Owner Spirit lake Dickinson Iowa Brianna Lene Nicholas Omang Signed
661 2023-04-29 10:04 Anonymous (not verified) 94.188.205.177 Planetary Tree Service 166 Brovan blvd, evansdale, iowa 50707 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-04-29 Andrew Jon Collins thetreeguy2000@gmail.com Evansdale Black Hawk Iowa Jennifer Selleck Carolyn Inman Signed (1) The corporation rejects the employers’ liability coverage. Andrew Jon Collins thetreeguy2000@gmail.com Owner Evansdale Black hawk Iowa Jennifer renee selleck Carolyn kay Inman 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
164 2021-01-20 11:11 Anonymous (not verified) 173.233.46.58 Wasmer Post 241, Department of Iowa dba The American Legion 110 Plymouth St SW, Le Mars, IA 51031 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-13 Andrew M. Schultze mrkmjm@yahoo.com Le Mars Plymouth IA Muriel J. Miller Richard P. Miller Signed (1) The corporation rejects the employers’ liability coverage. Gary L. Konz claim_buster@yahoo.com Financial Officer Le Mars Plymouth IA Muriel J. Miller Richard P. Miller Signed
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
888 2024-02-12 12:35 Anonymous (not verified) 94.188.205.167 Standard Builders DBA Midwest Seamless 1930 e army post rd., 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. 2024-02-12 Andy and Axell Construction LLC bradymaher9@gmail.com Des Moines Polk IA Michael Maher Brady Maher Signed (1) The corporation rejects the employers’ liability coverage. michael maher mikemaher@midwestseamless.com Owner/President PRAIRIE CITY Jasper IA Brady Maher fernando perez Signed
142 2020-12-02 09:39 Anonymous (not verified) 208.90.15.53 Humboldt Community Daycare, Inc. DBA Kiddie Cats Childcare and Learning Center P.O. Box 93 Dakota City, Ia 50529 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. 2020-12-02 Angelique Berry dcity@goldfieldaccess.net Algona Kossuth Iowa Ross Sleiter Scott Curran Signed (1) The corporation rejects the employers’ liability coverage. Angelique Berry dcity@goldfieldaccess.net Secretary/Treasurer Algona Kossuth Iowa Ross Sleiter Scott Curran Signed
475 2022-05-19 10:11 Anonymous (not verified) 172.86.13.54 BOLT HOLDINGS Inc. and Holt Precision dba Holt Bladeworks and Holt Kinetic Solutions 3230 N. Center Point Rd Unit 204, Marion, IA 52302 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-19 Angey Holt Angey@Holtkineticsolutions.com Robins Linn Iowa Lisa Gleason Danielle Congleton Signed (1) The corporation rejects the employers’ liability coverage. Lisa Gleason Lisa@holtkineticsolutions.com General Manager Marion Linn Iowa Danielle Congleton Joe Holt Signed
170 2021-01-26 12:23 Anonymous (not verified) 74.84.91.178 Sunset Ridge Winery LLC 12615 Highway 52 North, Dubuque, IA 52002 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-07 Ann Bonnette jbonnette@yahoo.com Dubuque Dubuque Iowa Derrick Parsons Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. Ann Bonnette jbonnette@yahoo.com Officer Dubuque Dubuque Iowa Derrick Parsons Brenda Lewis Signed
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
645 2023-03-31 08:55 Anonymous (not verified) 94.188.205.166 3Fitt Life, 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. 2023-03-31 Ann L Wachtel annw@3fitt.com Bellevue Jackson Iowa Jeff Laban Katie Laban Signed (1) The corporation rejects the employers’ liability coverage. Ann L Wachtel annw@3fitt.com President Bellevue Jackson Iowa Jeff Laban Katie Laban Signed
537 2022-09-20 09:01 Anonymous (not verified) 173.20.206.50 Accent Painting LLC 613 Locust 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. 2022-09-20 Anthony Gilbert Gasco accentpainting@yahoo.com La Porte City Blackhawk Iowa Arthur Rudolf Gasco Aurora Jealee Gasco Signed (1) The corporation rejects the employers’ liability coverage. Anthony Gilbert Gasco accentpainting@yahoo.com Owner La Porte City Blackhawk Iowa Arthur Rudolf Gasco Aurora Jealee Gasco Signed
369 2021-11-30 09:37 Anonymous (not verified) 173.19.234.191 Brezina Homes, Inc 9008 NW 73rd Place, Johnston, IA 50131 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-11-30 Anthony L. Brezina Tony.brezina@cbdsm.com West Des Moines Dallas Iowa Christopher Winterboer Melissa Winterboer Signed (1) The corporation rejects the employers’ liability coverage. Allen J. Brezina a.brezina@mchsi.com President Johnston Polk Iowa Christopher Winterboer Melissa Winterboer Signed
956 2024-04-12 14:23 Anonymous (not verified) 205.221.255.62 All things power wash ATP LLC 2730 Lafayette, 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. 2024-04-12 Anthony Rowe allthingspowerwash4usiouxcity@gmail.com Sioux City Woodbury Iowa Franzis Rios Tamara Bawi Signed (1) The corporation rejects the employers’ liability coverage. Anthony Rowe allthingspowerwash4usiouxcity@gmail.com Owner Sioux City Woodbury Iowa Franzis Rios Tamara Bawi Signed
185 2021-02-23 15:16 Anonymous (not verified) 173.29.151.168 TONY V'S PAINTING 2316 CRESCENT AVE 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. 2021-02-23 ANTHONY VANCE ANTHONYJV1977@GMAIL.COM DAVENPORT SCOTT IA TONY BURKHART RICHARD MILLER-VANCE Signed (1) The corporation rejects the employers’ liability coverage. ANTHONY VANCE ANTHONYJV1977@GMAIL.COM OWNER DAVENPORT SCOTT IA TONY BURKHART RICHARD MILLER-VANCE Signed
644 2023-03-31 08:47 Anonymous (not verified) 94.188.205.175 HDEZ, LLC 7500 Bloomfield Rd, Lot 91, Des Moines, IA 50320 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-31 Antonio Rosales tonyh873@gmail.com Des Moines Polk Iowa Ronald Barton Scott Grimm Signed (1) The corporation rejects the employers’ liability coverage. Antonio Rosales tonyh873@gmail.com Self Des Moines Polk Iowa Ronald Barton Scott Grimm Signed
904 2024-02-28 06:52 Anonymous (not verified) 94.188.205.167 Monarca General Builders LLC. 551 Martin Rd Waterloo Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-28 Antonio Serrato Sánchez assmsaeaj@icloud.com Waterloo Black Hawk Iowa Maria santos Juarez Adan Alvarez Signed (1) The corporation rejects the employers’ liability coverage. Antonio Serrato Sánchez assmsaeaj@icloud.com President Waterloo Black Hawk Iowa Maria santos Juarez Adan Alvarez Signed