347 |
2021-10-14 19:28 |
Anonymous (not verified) |
75.162.50.106 |
Dawn's Daycare |
360 NW Walnut Ave Earlham,Iowa 50072 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-14 |
James J Stonehocker |
j_stonehocker@hotmail.com |
Earlham |
Madison |
iowa |
Anne Larson |
Alison Werts |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James J Stonehocker |
j_stonehocker@hotmail.com |
Owner |
Earlham |
Madison |
Iowa |
Anne Larson |
Alison Werts |
Signed |
348 |
2021-10-20 11:06 |
Anonymous (not verified) |
97.116.100.220 |
Gonzalo construction LLC |
5517 Brookdale Dr n apt 105 Brooklyn Park, mn 55443 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-20 |
Gonzalo Roman robles |
gonzaloconstructionmn@gmail.com |
Brooklyn park |
Hennepin |
Minnesora |
Gonzalo Roman robles |
Ashley Kraft |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gonzalo Roman robles |
gonzaloconstruction@gmail.com |
Owner |
Brooklyn park |
Hennepin |
Minnesota |
Gonzalo Roman robles |
Ashley Kraft |
Signed |
349 |
2021-10-22 11:08 |
Anonymous (not verified) |
63.152.48.235 |
Strong Rock and Gravel LLC |
721 S Front St, Lansing, IA 52151 |
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. |
2021-09-04 |
Ronald Strong |
stronggravel@gmail.com |
Llansing |
Allamakee |
Iowa |
James H Bieber |
Jane Tepesch |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James H Bieber |
biebinre@qwestoffice.net |
Insurance Agent |
WAUKON |
Allamakee |
Iowa |
James H Bieber |
Jane Tepesch |
Signed |
350 |
2021-10-25 08:22 |
Anonymous (not verified) |
208.95.64.3 |
Ron Sexton Construction Inc, |
1184 Vine Ave, Riverside IA 52327 |
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. |
2021-09-27 |
Ronald R Sexton |
ashmac@iowatelecom.net |
Riverside |
Washington |
IA |
Greg Martin |
Michele McMichael |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ronald R Sexton |
ashmac@iowatelecom.net |
President |
Riverside |
Washington |
IA |
Greg Martin |
Michele McMichael |
Signed |
351 |
2021-10-25 08:24 |
Anonymous (not verified) |
208.95.64.3 |
Ron Sexton Construction Inc, |
1184 Vine Ave, Riverside IA 52327 |
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. |
2021-09-27 |
Theresa A Sexton |
ashmac@iowatelecom.net |
Riverside |
Washington |
IA |
Greg Martin |
Michele McMichael |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Theresa A Sexton |
ashmac@iowatelecom.net |
VP, Secretary, Treasurer |
Riverside |
Washington |
IA |
Greg Martin |
Michele McMichael |
Signed |
352 |
2021-10-27 12:59 |
Anonymous (not verified) |
206.80.128.65 |
Employee Fringes Audit Co |
710 N Buxton St, Indianola, IA 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. |
2021-10-27 |
Patrick Heller |
patjh@yahoo.com |
Indianola |
Warren |
IOWA |
Joseph McCollum |
Heather Husman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Judith Heller |
patjh@yahoo.com |
Owner |
Indianola |
Warren |
Iowa |
Joseph McCollum |
Heather Husman |
Signed |
353 |
2021-11-04 11:41 |
Anonymous (not verified) |
108.58.173.242 |
ASTL Moving And Storage Inc |
9530 FM 2920 #227 Tomball TX 77375 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-11-04 |
Peter Allen III |
astlmoving@yahoo.com |
Tomball |
Harris |
TX |
Peggi Makofka |
Yoel Taran |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Peter Allen III |
astlmoving@yahoo.com |
owner |
Tomball |
Harris |
TX |
Peggi Makofka |
Yoel Taran |
Signed |
354 |
2021-11-04 16:26 |
Anonymous (not verified) |
97.64.194.58 |
D&D Construction |
1124 West Donald ST, Waterloo IA 50703 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-11-04 |
Darrel Caldwell |
dcaldwell1124@yahoo.com |
Waterloo |
Black Hawk County |
IA |
Scott Joseph Demuth |
Catrese Caldwell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
NA |
dcaldwell1124@yahoo.com |
NA |
NA |
NA |
NA |
NA |
NA |
Signed |
355 |
2021-11-05 15:04 |
Anonymous (not verified) |
209.252.172.87 |
S&S Window Treatments Inc. |
2555 Hwy 1 SW, Iowa City, IA 52240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-11-20 |
Joshua Yoder |
installation@bachmeiercarpetone.com |
Iowa City |
Johnson |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joshua Yoder |
installation@bachmeiercarpetone.com |
Owner |
Iowa City |
Johnson |
Iowa |
Sarah Coberley |
Heather Howell |
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 |
358 |
2021-11-15 09:39 |
Anonymous (not verified) |
165.225.57.41 |
Jerry Steward Trucking Inc. |
319 W. 7th Street, Janesville, IA 50647 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-22 |
Jerry Steward Sr. |
cedarfalls.oil@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jerry Steward Jr. |
cedarfalls.oil@gmail.com |
Vice-President |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
359 |
2021-11-15 09:43 |
Anonymous (not verified) |
165.225.57.41 |
Jerry Steward Trucking Inc |
319 W. 7th Street, Janesville, IA 50647 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-22 |
Jerry Steward Jr. |
cedarfalls.oil@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jerry Steward Sr. |
cedarfalls.oil@gmail.com |
President |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
360 |
2021-11-15 09:47 |
Anonymous (not verified) |
165.225.57.41 |
Jerry Steward Trucking Inc |
319 W. 7th Street, Janesville, IA 50647 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-22 |
Ruth Steward |
cedarfalls.oil@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jerry Steward Sr. |
cedarfalls.oil@gmail.com |
President |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
361 |
2021-11-15 18:08 |
Anonymous (not verified) |
199.66.15.123 |
Wills Work |
302 N Kenwood Blvd |
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. |
2021-11-15 |
Timothy Williams Robinson |
williamswork18@gmail.com |
Indianola |
Warren |
Iowa |
Andrew Gilbert Barber |
Sarah Anne Robinson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Timothy Will Robinson |
williamswork18@gmail.com |
CEO |
Indianola |
Warren |
Iowa |
Andrew Gilbert Barber |
Sarah Anne Robinson |
Signed |
362 |
2021-11-16 11:20 |
Anonymous (not verified) |
63.227.65.43 |
F&H Aluminum, Inc. |
101 E. Corporate Drive Charles City, Iowa 50616 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-11-16 |
DeWayne Ferch |
fhaluminum@netconx.net |
Kensett |
Worth |
Iowa |
Tom Stephany |
Amanda Korenberg |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
DeWayne Ferch |
fhaluminum@netconx.net |
President |
Kensett |
Worth |
Iowa |
Tom Stephany |
Amanda Korenberg |
Signed |
363 |
2021-11-17 09:33 |
Anonymous (not verified) |
64.5.67.201 |
OC Deliver Inc |
207 Central Avenue NE, 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. |
2021-10-25 |
Joe Clarey |
ciui@orangecitycomm.net |
LeMars |
Plymouth |
Iowa |
Daryl Beltman |
Lori Mars |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joe Clarey |
ciui@orangecitycomm.net |
President |
LeMars |
Plymouth |
Iowa |
Daryl Beltman |
Lori Mars |
Signed |
364 |
2021-11-17 09:36 |
Anonymous (not verified) |
64.5.67.201 |
OC Deliver Inc |
207 Central Avenue NE, 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. |
2021-10-25 |
Josh Van Es |
ciui@orangecitycomm.net |
Orange City |
Sioux |
Iowa |
Daryl Beltman |
Lori Mars |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Josh Van Es |
ciui@orangecitycomm.net |
Secretary/Treasurer |
Orange City |
Sioux |
Iowa |
Daryl Beltman |
Lori Mars |
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 |
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 |
367 |
2021-11-23 12:23 |
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 |
Monica M. 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 |
368 |
2021-11-24 07:11 |
Anonymous (not verified) |
173.20.97.32 |
Neppl Landscape Architecture and Planning, LLC |
3013 Briggs Circle Ames, Iowa 50010 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-11-24 |
Thomas George Neppl |
tom@tomneppl.com |
Ames |
Story |
Iowa |
Ashlyn Kay Neppl |
Tricia Kay Neppl |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Thomas George Neppl |
tom@tomneppl.com |
Owner |
Ames |
Story |
Iowa |
Ashlyn Kay Neppl |
Tricia Kay Neppl |
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 |
370 |
2021-12-07 10:08 |
Anonymous (not verified) |
208.126.71.193 |
Ryco Customs, Inc. |
2920 4th Ave S., Clear Lake, IA 50428 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-12-07 |
Ryan Ruter |
ryan@rycocustoms.com |
Clear Lake |
Cerro Gordo |
Iowa |
Kimberly M Martin |
Taylor Weiland |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ryan Ruter |
ryan@rycocustoms.com |
Owner |
Clear Lake |
Cerro Gordo |
Iowa |
Kimberly M Martin |
Taylor Weiland |
Signed |
371 |
2021-12-09 11:03 |
Anonymous (not verified) |
216.81.176.153 |
Concentric International Inc. |
1901 Bell Ave Ste 18, Des Moines, IA 50315-1067 |
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. |
2021-12-09 |
Tracey Ball |
tball@ruan.com |
Urbandale |
IA |
United States |
Jackie Walker |
Craig Gesme |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tracey Ball |
tball@ruan.com |
Treasurer |
Urbandale |
IA |
United States |
Jackie Walker |
Craig Gesme |
Signed |
372 |
2021-12-09 14:17 |
Anonymous (not verified) |
204.155.61.217 |
Buena Vista Auto Sales Inc |
1030 Lake Ave, Storm Lake, IA 50588 |
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. |
2021-12-09 |
Arturo Lozano |
bvusedcars@siouxland.com |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Michelle Munoz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Arturo Lozano |
bvusedcars@siouxland.com |
Owner |
storm Lake |
Buena Vista |
IA |
Jared Brashears |
Michelle Munoz |
Signed |
373 |
2021-12-10 14:49 |
Anonymous (not verified) |
173.29.69.100 |
CARSTENS FLOOR COVERINGS LLC |
19276 250TH STREET ELDRIDGE, IA 52748 |
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. |
2021-12-10 |
MATHEW CARSTENS |
MCARSTENS@NETINS.NET |
ELDRIDGE |
SCOTT |
IA |
TONY BURKHART |
BETH LEMONS |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
MATTHEW CARSTENS |
MCARSTENS@NETINS.NET |
PRESIDENT |
ELDRIDGE |
SCOTT |
IA |
TONY BURKHART |
BETH LEMONS |
Signed |
374 |
2021-12-17 08:19 |
Anonymous (not verified) |
69.63.16.2 |
AT Construction Inc. |
5 Westview Acres NE, Iowa City IA 52240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-12-17 |
Tomas Acas |
atconstruction@hotmail.com |
Iowa City |
Johnson |
Iowa |
Steve Fishman |
Dyan Kriener |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tomas Acas |
atconstruction@hotmail.com |
President |
Iowa City |
Johnson |
Iowa |
Steve Fishman |
Dyan Kriener |
Signed |
375 |
2021-12-23 12:23 |
Anonymous (not verified) |
66.230.245.47 |
W. R. Elliot & Associates, Ltd. |
3306 Brook Hollow Dr, Asbury, IA 52002 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-12-23 |
William R. Elliot |
bill@wreassoc.com |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L. Spalla |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William R. Elliot |
bill@wreassoc.com |
President |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L Spalla |
Signed |
376 |
2021-12-29 14:40 |
Anonymous (not verified) |
66.230.245.47 |
W. R. Elliot & Associates, Ltd. |
3306 Brook Hollow Dr, Asbury, IA 52002 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-12-29 |
Karen R. Elliot |
karen@handiwerks.com |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L Spalla |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William R. Elliot |
bill@wreassoc.com |
President |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L Spalla |
Signed |
377 |
2021-12-30 11:42 |
Anonymous (not verified) |
216.51.165.122 |
M and K Rentals Inc. |
800 Country Club Drive, Maquoketa, IA 52060 |
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. |
2021-12-17 |
Mark F Intlekofer |
kmintlekofer@yahoo.com |
Maquoketa |
Jackson |
Iowa |
Deb L Lane |
Rachelle Zeimet |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mark F Intlekofer |
kmintlekofer@yahoo.com |
President |
Maquoketa |
Jackson |
Iowa |
Deb L Lane |
Rachelle Zeimet |
Signed |
378 |
2022-01-03 15:16 |
Anonymous (not verified) |
217.180.230.157 |
True360, Inc. |
1805 Collaboration Place, Suite 1300, Ames, Iowa 50010 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-03 |
Christopher James |
chris@true-360.com |
Ames |
Iowa |
United States |
Jesse Kisker |
Cody Kapka |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christopher James |
chris@true-360.com |
President and Chief Executive Officer |
Ames |
Iowa |
United States |
Jesse Kisker |
Cody Kapka |
Signed |
379 |
2022-01-04 14:10 |
Anonymous (not verified) |
97.107.199.129 |
Premier Show Productions |
1304 Skyline Dr Council Bluffs IA |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-20 |
Scott Brandenburg |
scottsuperiorservices@gmail.com |
Council Bluffs |
POtt |
Iowa |
Jan andersen |
Brad Andersen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott Brandenburg |
scottsuperiorservices@gmail.com |
self |
Council Bluffs |
Pott |
Iowa |
Jan Andersen |
Brad Andersen |
Signed |
380 |
2022-01-04 15:21 |
Anonymous (not verified) |
97.107.199.129 |
Moval Motors LLC |
3153 Joliet Ave, Missouri Valley IA |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-12-21 |
Jon Paul Burton |
jonpaulburton@gmail.com |
OMAHA |
Douglas |
NE |
Pam Kreitzinger |
Scott Porter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jon Paul Bruton |
jonpaulburton@gmail.com |
self |
Omaha |
Douglas |
NE |
Pam Kreitzinger |
Scott Porter |
Signed |
381 |
2022-01-04 15:24 |
Anonymous (not verified) |
97.107.199.129 |
Moval Motors LLC |
3153 Joliet Ave, Missouri Valley 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. |
2022-01-03 |
Scott Porter |
sporter51503@gmail.com |
Iowa |
Pottawattamie |
IA |
John Burton |
Pam Kreitzinger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott Porter |
sporter51503@gmail.com |
self |
Omaha |
Pottawattamie |
IA |
Jon Burton |
Pam Kreitzinger |
Signed |
382 |
2022-01-05 14:05 |
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. |
2022-01-05 |
Jennifer Brezina |
Jenniferfisher71979@gmail.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 |
383 |
2022-01-06 11:20 |
Anonymous (not verified) |
209.152.125.156 |
Hill Lawn Care |
2307 Campbell Dr Marshalltown Iowa 50158 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-06 |
Raymond Hill |
Rayhill_19@hotmail.com |
Marshalltown |
Marshall |
Iowa |
Kaitlyn Schuring |
Matt Gannaway |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Raymond Hill |
Rayhill_19@hotmail.com |
Owner |
Marshalltown |
Marshall |
Iowa |
Kaitlyn Schuring |
Matt Gannaway |
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 |
387 |
2022-01-11 11:11 |
Anonymous (not verified) |
216.51.165.122 |
M & K Rentals Inc |
800 Country Club Dr, Maquoketa IA 52060 |
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. |
2021-12-20 |
Mark F Intlekofer |
kmintlekofer@yahoo.com |
MAQUOKETA |
Jackson |
Iowa |
Rachelle Zeimet |
Justin Meade |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mark F Intlekofer |
kmintlekofer@yahoo.com |
President |
Maquoketa |
Jackson |
Iowa |
Rachelle Zeimet |
Justin Meade |
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 |
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 |
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 |
392 |
2022-01-26 16:11 |
Anonymous (not verified) |
207.199.212.86 |
Geerts Plumbing and Heating |
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. |
2021-07-21 |
Brenda Geerts |
lacy@cioia.com |
New Hampton |
Chickasaw |
Iowa |
Lacy Carolan |
Tony Trower |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brenda Geerts |
lacy@cioia.com |
Owner |
New Hampton |
Chickasaw |
Iowa |
Lacy Carolan |
Tony Trower |
Signed |
393 |
2022-01-26 16:35 |
Anonymous (not verified) |
216.51.137.244 |
Metal Works, Inc. |
1015 32nd Ave W, Spencer, IA 51301 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-01 |
Ben Nystrom |
ffernandez@thamsagency.com |
Spencer |
Clay |
Iowa |
Phil Ramstack |
Francia Fernandez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ben Nystrom |
ffernandez@thamsagency.com |
Owner |
Spencer |
Clay |
Iowa |
Philp Ramstack |
Francia Fernandez |
Signed |
394 |
2022-01-27 12:29 |
Anonymous (not verified) |
72.255.65.83 |
Rodgers’ Building & Remodeling Inc |
1003 NW 37th Street |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-28 |
Benjamin Rodgers |
btrdsm18@gmail.com |
Ankeny |
Polk |
Iowa |
Mary Rodgers |
Larry Joel |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mary Rodgers |
steff.m2096@yahoo.com |
President |
Ankeny |
Polk |
Iowa |
Ben Rodgers |
Larry Joel |
Signed |
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 |
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 |
397 |
2022-02-01 10:30 |
Anonymous (not verified) |
159.242.43.24 |
Providence Casework |
PO Box 205 Rockwell, IA 50469 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-01 |
Neal Keeling |
office@procaseworks.com |
Rockwell |
Cerro Gordo |
Iowa |
Josh Olson |
John Moran |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Neal Keeling |
office@procaseworks.com |
Owner |
Rockwell |
Cerro Gordo |
Iowa |
Josh Olson |
John Moran |
Signed |
398 |
2022-02-01 18:50 |
Anonymous (not verified) |
172.58.83.243 |
essential renovation LLC |
516 e center st, freeport il |
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. |
2022-02-01 |
teodoro jimenez |
essentialrenovations.llc@gmail.com |
freeport |
stephenson |
il |
adam spear |
karly spear |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
sandra cuatlatl |
essentialrenovations.llc@gmail.com |
owner |
freeport |
stephenson |
il |
adam spear |
karly spear |
Signed |
399 |
2022-02-03 09:03 |
Anonymous (not verified) |
207.199.230.75 |
Heart of Iowa Inspections LLC |
2700 Highway 63 Oskaloosa Iowa 52577 |
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. |
2022-02-03 |
Randy DeHeer |
rdeheer2828@gmail.com |
Oskaloosa |
Mahaska |
Iowa |
Doris Crile |
Cheryl Brown |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Randy DeHeer |
rdeheer2828@gmail.com |
self |
Oskaloosa |
Mahaska |
Iowa |
Doris Crile |
Cheryl Brown |
Signed |