59 |
2020-04-14 12:54 |
Anonymous (not verified) |
65.126.161.162 |
Elite Carpentry |
1515 21st Street Bettendorf, IA 52722 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-10 |
Jeffrey D. Leech |
elitecarpentryqc@gmail.com |
Bettendorf |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Jeffrey D. Leech |
elitecarpentryqc@gmail.com |
President |
Bettendorf |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
77 |
2020-05-05 16:47 |
Anonymous (not verified) |
173.21.16.121 |
Kevan Oliver Trim Carpentry, Inc. |
2900 Scott Park Road, 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. |
(2) I decline to reject the employer’s liability coverage. |
2020-05-05 |
Kevan Oliver |
kkoliverinc@gmail.com |
Eldridge |
Scott |
Iowa |
Franco Muñoz |
Rolando Muñoz |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Kevan Oliver |
kkoliverinc@gmail.com |
President |
Eldridge |
Scott |
Iowa |
Franco Muñoz |
Rolando Muñoz |
Signed |
78 |
2020-05-05 16:49 |
Anonymous (not verified) |
173.21.16.121 |
Kevan Oliver Trim Carpentry, Inc. |
2900 Scott Park Road, 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. |
(2) I decline to reject the employer’s liability coverage. |
2020-05-05 |
Scarlett Oliver |
scarlettioliver@gmail.com |
Eldridge |
Scott |
Iowa |
Franco Muñoz |
Rolando Muñoz |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Kevan Oliver |
kkoliverinc@gmail.com |
President |
Eldridge |
Scott |
Iowa |
Franco Muñoz |
Rolando Muñoz |
Signed |
98 |
2020-07-11 16:34 |
Anonymous (not verified) |
50.83.184.81 |
Paradigm Construction LLC |
1847 nw 90th st Clive, IA 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-06 |
Jonathon Richard Curtis |
joncurtis15@gmail.com |
Des Moines |
Polk |
IA |
Yolanda Curtis |
Susan Brooker |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Ryan Shabino |
ryan@prdgmconstruction.com |
Contractor |
Clive |
Polk |
IA |
Yolanda Curtis |
Susan Brooker |
Signed |
103 |
2020-07-23 09:23 |
Anonymous (not verified) |
184.80.177.137 |
Jacob Reiff |
15738 N Cascade Rd - Peosta, IA 52068 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2020-07-23 |
Jacob Reiff |
jheims@engish-insurance.com |
Peosta, |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
owner |
Peosta |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
123 |
2020-10-20 17:35 |
Anonymous (not verified) |
66.172.250.9 |
Ladwig Constrution |
509 Moorehead St. Ida Grove, IA 51445 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-10-20 |
Ross Ladwig |
rossladwig@gmail.com |
Ida Grove |
Ida |
Iowa |
Christine Ladwig |
Kya Ladwig |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Ross Ladwig |
rossladwig@gmail.com |
Owner |
Ida Grove |
Ida |
Iowa |
Christine Ladwig |
Kya Ladwig |
Signed |
153 |
2021-01-06 13:20 |
Anonymous (not verified) |
167.142.147.6 |
PACIFIC DRYWALL CORPORATION |
105 SNYDER DRIVE HUXLEY, IOWA 50124 |
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. |
2021-01-06 |
JUAN JOSE AVALOS CASTELLANOS |
PACIFICDRYWALLCORP@GMAIL.COM |
ANKENY |
POLK |
IOWA |
JENNIFER LYNNE ESCOBAR |
LUIS MANUEAL AVALOS CASTELANOS |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
JUAN JOSE AVALOS CASTELLANOS |
PACIFICDRYWALLCORP@GMAIL.COM |
VICE PRESIDENT |
ANKENY |
POLKC |
IOWA |
JENNIFER LYNNE ESCOBAR |
LUIS MANUEL AVALOS CASTELANOS |
Signed |
154 |
2021-01-06 13:23 |
Anonymous (not verified) |
167.142.147.6 |
PACIFIC DRYWALL CORPORATION |
105 SNYDER DRIVE HUXLEY, IOWA 50124 |
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. |
2021-01-06 |
LUIS MANUEL AVALOS CASTELANOS |
PACIFICDRYWALLCORP@GMAIL.COM |
DES MOINES |
POLK |
IOWA |
JENNIFER LYNNE ESCOBAR |
JUAN JOSE AVALOS CASTELLANOS |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
LUIS MANUEL AVALOS CASTELANOS |
PACIFICDRYWALLCORP@GMAIL.COM |
PRESIDENT |
DES MOINES |
POLK |
IOWA |
JUAN JOSE AVALOS CASTELLANOS |
JENNIFER LYNNE ESCOBAR |
Signed |
176 |
2021-02-03 15:02 |
Anonymous (not verified) |
174.198.90.166 |
Jesse's Embers LLC |
3301 Ingersoll Ave, Des Moines, IA, 50312 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-03 |
Deena Edelstein |
dledelstein@hotmail.com |
Des Moines |
Polk |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Deena Edelstein |
dledelstein@hotmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
177 |
2021-02-03 15:07 |
Anonymous (not verified) |
174.198.90.166 |
Jesse's Embers LLC |
3301 Ingersoll Ave, Des Moines, IA, 50312 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-03 |
Martin Scarpino |
martyscarpino@yahoo.com |
Des Moines |
Polk |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Martin Scarpino |
martyscarpino@yahoo.com |
Owner |
Des Moines |
IA |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
193 |
2021-03-02 11:32 |
Anonymous (not verified) |
50.83.72.164 |
4 corners drywall |
532 w 15 st, Davenport, iowa 52803 |
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. |
2021-03-02 |
Phillip hoxsey |
Phillhoxsey81@gmail.com |
Davenport |
Scott |
Iowa |
Donivan hoxsey |
Connor ruge |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Phillip hoxsey |
Phillhoxsey81@gmail.com |
Owner |
Davenport |
Scott |
Iowa |
Donivan hoxsey |
Connor ruge |
Signed |
194 |
2021-03-02 11:42 |
Anonymous (not verified) |
50.83.72.164 |
D’s Drywall |
1217 n Blanchard 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. |
(2) I decline to reject the employer’s liability coverage. |
2021-03-02 |
Donivan hoxsey |
hdonivan@gmail.com |
Davenport |
Scott |
Iowa |
Phillip hoxsey |
Connor ruge |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Donivan hoxsey |
hdonivan@gmail.com |
Owner |
Davenport |
Scott |
Iowa |
Phillip hoxsey |
Connor ruge |
Signed |
195 |
2021-03-02 16:29 |
Anonymous (not verified) |
173.29.156.163 |
Certified drywall |
329 e.11th st Davenport, Iowa 52803 |
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. |
2021-03-02 |
Thomas wells |
mikeparry783@gmail.com |
Davenport |
Scott |
Iowa |
Chyna rose pena |
Natalie parry |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Thomas wells |
mikeparry783@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Chyna rose pena |
Natalie parry |
Signed |
198 |
2021-03-03 17:14 |
Anonymous (not verified) |
173.29.156.163 |
Jdw |
329 E. 11th st davenport 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. |
2021-03-03 |
James holzer |
slickninja00@gmail.com |
Davenport |
Scott |
Iowa |
Alyssa holzer |
Kory munn |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
James holzer |
slickninja00@gmail.com |
Myself |
Davenport |
Scott |
Iowa |
Alyssa holzer |
Kory munn |
Signed |
204 |
2021-03-08 10:43 |
Anonymous (not verified) |
151.147.196.21 |
Iowa Gold Distributing, Inc. |
600 Iehl Street, Central City, IA 52214 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2021-02-10 |
Brad Coates |
igdenv@aol.com |
Central City |
Linn |
Iowa |
William Walters |
Jennifer Leinen |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Brad Coates |
igdenv@aol.com |
Director |
Central City |
Linn |
Iowa |
William Walters |
Jennifer Leinen |
Signed |
205 |
2021-03-10 09:55 |
Anonymous (not verified) |
173.27.221.9 |
Tri State Archery, Inc |
2100 White St, Dubuque IA 52001 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-14 |
Denise Udelhofen |
office@tristateoutdoors.net |
Dubuque |
Dubuque |
Iowa |
Phillip J Meyer |
Debbie Meyer |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Jeff Udelhofen |
office@tristateoutdoors.net |
President |
Dubuque |
Dubuque |
IA |
Phillip Meyer |
Debbie Meyer |
Signed |
208 |
2021-03-16 16:19 |
Anonymous (not verified) |
204.155.61.217 |
AGSPIRE INC |
1310 Kathryn Ct Buffalo, MN 55313 |
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. |
2021-02-02 |
Kent Kiebelkorn |
kent@hailmayday.com |
Buffalo |
Wright County |
Minnesota |
Docusign |
Docusign |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
unknown |
akraft@millerhartwig.com |
Unknown |
unknown |
unknown |
unknown |
unknown |
unknown |
Signed |
229 |
2021-04-05 13:44 |
Anonymous (not verified) |
173.18.193.51 |
Denmark Sanitary District |
PO Box 141, Denmark, Iowa 52624 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-03 |
Clay Fullenkamp |
judy@fullenkampins.com |
West Point |
Lee |
Iowa |
Judy Moeller |
Brian Stuekerjuergen |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Clay Fullenkamp |
judy@fullenkampins.com |
Board Member |
West Point |
Lee |
Iowa |
judy moeller |
brian stuekerjuergen |
Signed |
230 |
2021-04-06 21:15 |
Anonymous (not verified) |
173.23.145.187 |
Jose J Framing |
5301 SE 24th St. 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. |
(2) I decline to reject the employer’s liability coverage. |
2021-01-01 |
Jose J. Castillo |
castillojosejonathan7@gmail.com |
Des Moines |
Polk |
United States |
Perla Landaverde Garcia |
Alma Y. Gaytan |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Jose J. Castillo |
castillojosejonathan7@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Perla Landaverde Garcia |
Alma Y. Gaytan |
Signed |
232 |
2021-04-12 11:14 |
Anonymous (not verified) |
74.84.91.178 |
Heim Enterprises LLC |
13532 Mueller Parkway, Sherrill, IA 52073 |
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. |
2021-04-01 |
Cory Heim |
corypheim@gmail.com |
Sherrill |
Dubuque |
Iowa |
Gabe Drewelow |
Brenda Lewis |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Cory Heim |
corypheim@gmail.com |
owner |
Sherrill |
Dubuque |
Iowa |
Gabe Drewelow |
Brenda Lewis |
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 |
265 |
2021-05-22 13:33 |
Anonymous (not verified) |
75.162.162.238 |
Superior Painting and Remodeling, corp |
8415 Franklin Ave. Apt. 49 Clive, Iowa 50325 |
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. |
2021-05-22 |
Luz Maria Morales Gutierrez |
lm3673719@gmial.com |
Des Moines |
USA |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Luz Maria Morales Gutierrez |
lm3673719@gmial.com |
Owner |
Des Moines |
USA |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
266 |
2021-05-22 13:38 |
Anonymous (not verified) |
75.162.162.238 |
Superior Painting and Remodeling, corp |
8415 Franklin Ave. Apt. 49 Clive, Iowa 50325 |
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. |
2021-05-22 |
Elmer Lopez Montufar |
lm3673719@gmial.com |
Des Moines |
USA |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Superior Painting and Remodeling Corp |
lm3673719@gmial.com |
Owner |
Des Moines |
USA |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
275 |
2021-06-15 13:23 |
Anonymous (not verified) |
172.98.131.84 |
JAVIER CONSTRUCTION INC |
2503 Canyon St SW Cedar Rapids, IA 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-06-15 |
Javier Adana |
Javierconstruction88@gmail.com |
CEDAR RAPIDS |
LINN |
IOWA |
JASON SCHICK |
LADONNA SCHICK |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
JASON SCHICK |
JASONSCHICK@NEIGHBORINSURANCE.COM |
INSURANCE AGENT |
CEDAR RAPIDS |
LINN |
IOWA |
JASON SCHICK |
LADONNA SCHICK |
Signed |
278 |
2021-06-18 11:37 |
Anonymous (not verified) |
75.162.29.203 |
Digital Agronomy, LLC |
4270 199th St. Ames, IA 50014 |
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. |
2021-06-17 |
Patrick T. Murphy |
ptmurphy82@gmail.com |
Ames |
Story |
Iowa |
David Cory |
Mary Cory |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Patrick T. Murphy |
ptmurphy82@gmail.com |
Owner |
Ames |
Story |
Iowa |
David Cory |
Mary Cory |
Signed |
283 |
2021-06-30 14:24 |
Anonymous (not verified) |
75.162.212.130 |
Superior Painting and Remodeling, corp |
8415 Franklin Ave Apt 49 Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-06-30 |
Luz Maria Morales Gutierrez |
lm3673719@gmail.com |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Luz Maria Morales Gutierrez |
lm3673719@gmail.com |
Owner |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
284 |
2021-06-30 14:27 |
Anonymous (not verified) |
75.162.212.130 |
Superior Painting and Remodeling, corp |
8415 Franklin Ave Apt 49 Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-06-30 |
Elmer Lopes Montufar |
lm3673719@gmail.com |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Superior Painting and Remodeling Corp |
lm3673719@gmail.com |
Owner |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
285 |
2021-06-30 14:33 |
Anonymous (not verified) |
75.162.212.130 |
Superior Painting and Remodeling, corp |
8415 Franklin Ave Apt 49 Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-06-30 |
Luz Maria Morales Gutierrez |
lm3673719@gmail.com |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Superior Painting and Remodeling Corp |
lm3673719@gmail.com |
Owner |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
325 |
2021-09-03 12:50 |
Anonymous (not verified) |
173.19.58.159 |
Oskaloosa Entertainment Inc. |
507 High Ave W Oskaloosa, IA 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. |
2021-08-11 |
Minesh Patel |
djraj007@gmail.com |
Oskaloosa |
Mahaska |
Iowa |
Joe Mauro |
Randy Mauro |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Joe Mauro |
joe@mauroinsurance.net |
insurance agent |
DES MOINES |
Polk |
Iowa |
Joe Mauro |
Randy Mauro |
Signed |
326 |
2021-09-03 12:56 |
Anonymous (not verified) |
173.19.58.159 |
Oskaloosa Entertainment Inc. |
507 High Ave W Oskaloosa, IA 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. |
2021-08-11 |
Rajan Devan |
djraj007@gmail.com |
West Des Moines |
Polk |
Iowa |
Joe Mauro |
Randy Mauro |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Joe Mauro |
joe@mauroinsurance.net |
insurance agent |
DES MOINES |
Polk |
United States |
Joe Mauro |
Randy Mauro |
Signed |
341 |
2021-10-05 13:52 |
Anonymous (not verified) |
98.22.0.231 |
Randall Roofing, Inc. |
1531 Shady Brook Lane, Pella, IA 50219 |
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. |
2021-10-10 |
Randall Bernard Jarzombek |
randy@randallroofs.com |
Pella |
Marion |
Iowa |
Mark Densmore |
Erica Clifford |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Randall Bernard Jarzombek |
randy@randallroofs.com |
Owner |
Pella |
Marion |
Iowa |
Mark Densmore |
Erica Clifford |
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 |
385 |
2022-01-11 08:27 |
Anonymous (not verified) |
173.29.238.103 |
Brilliant All-Seasons Lighting Inc. |
10357 NW 42nd St., Polk City, IA 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-11 |
Bradley Harold Loney |
bloney@live.com |
Polk City |
Polk |
Iowa |
Linda Delin |
Amanda Warywoda |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Katrina Loney |
katrinaloney@outlook.com |
Vice President |
Polk City |
Polk |
Iowa |
Linda Delin |
Amanda Warywoda |
Signed |
386 |
2022-01-11 08:30 |
Anonymous (not verified) |
173.29.238.103 |
Brilliant All-Seasons Lighting Inc. |
10357 NW 42nd St., Polk City, IA 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2022-01-11 |
Katrina Marie Loney |
katrinaloney@outlook.com |
Polk City |
Polk |
Iowa |
Linda Delin |
Amanda Warywoda |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Brad Loney |
bloney@live.com |
President |
Polk City |
Polk |
Iowa |
Linda Delin |
Amanda Warywoda |
Signed |
449 |
2022-04-19 21:09 |
Anonymous (not verified) |
172.86.44.178 |
Holtkamp Transportation LLC |
2282 Windmill Way, West Point, IA 52656 |
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. |
2022-04-19 |
Les Holtkamp |
les@holtkamplogistics.com |
West Point |
Lee |
Iowa |
Ben Hogan |
Tina Holtkamp |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Ben Hogan |
ben@truserveins.com |
Insurance Agent |
Readlyn |
Bremer |
Iowa |
Jaci Hogan |
Nicole Barnes |
Signed |
450 |
2022-04-20 13:42 |
Anonymous (not verified) |
96.85.81.137 |
D&K Harvesting Inc. |
P.o Box 1347 LaBelle Fl 33975 |
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. |
2022-04-20 |
James Larry Marsh Jr |
larrym3041@aol.com |
Fort myers |
Lee |
Florida |
Anita Coronado |
Christy Pequeno |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
James Larry Marsh Jr |
larrym3041@aol.com |
Owner |
Fort myers |
Lee |
Florida |
Anita Coronado |
Christy Puequeno |
Signed |
468 |
2022-05-12 11:33 |
Anonymous (not verified) |
173.23.25.243 |
RS Remodelers |
2863 104th St Urbandale IA 50322 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2022-05-12 |
Robert Nevitt |
rwnevitt@yahoo.com |
PERRY |
DALLAS |
IA |
Steve Dillon |
Jordan Nevitt |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Robert Nevitt |
clearchoicedesmoinesia@gmail.com |
Owner |
Urbandale |
Dallas |
ia |
Steve Dillon |
Jordan Nevitt |
Signed |
469 |
2022-05-12 11:38 |
Anonymous (not verified) |
173.23.25.243 |
RS- Remodelers |
2863 104th St Urbandale IA 50322 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2022-05-12 |
Stephen Dillon |
clearchoicedesmoinesia@gmail.com |
Waukee |
Dallas |
IA |
Rob Nevitt |
Jordan Nevitt |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Stephen |
clearchoicedesmoinesia@gmail.com |
Owner |
Waukee |
Dallas |
IA |
Rob Nevitt |
Jordan Nevitt |
Signed |
501 |
2022-06-24 12:10 |
Anonymous (not verified) |
173.31.148.43 |
HISTORIC ARNOLDS PARK INC |
37 LAKE ST ARNOLDS PARK, IA 51331 |
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. |
2022-06-24 |
JON PAUSLEY |
JON@ARNOLDSPARK.COM |
MILFORD |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
JON PAUSLEY |
JON@ARNOLDSPARK.COM |
CEO |
MILFORD |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
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 |
521 |
2022-07-25 15:33 |
Anonymous (not verified) |
199.66.14.149 |
ROSENBERGER ENTERPRISES, INC. |
1813 N 7th 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. |
2022-07-25 |
Diane Rosenberger |
diane@katanainc.com |
Indianola |
IA |
United States |
SPRING CRUBAUGH |
BRADY FRY |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Diane Rosenberger |
diane@katanainc.com |
Owner |
Indianola |
IA |
United States |
SPRING CRUBAUGH |
BRADY FRY |
Signed |
539 |
2022-09-22 18:03 |
Anonymous (not verified) |
166.181.87.86 |
Abarrotes La Salud, Inc. |
17 North 1st 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. |
(2) I decline to reject the employer’s liability coverage. |
2022-09-22 |
Gabriela Vargas Avalos |
mtownlasalud@gmail.com |
Marshalltown |
Marshall |
Iowa |
Antonio Ramirez Sanchez |
Genoveva Alvizu Hernandez |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Gabriela Vargas Avalos |
mtownlasalud@gmail.com |
Vice President |
Marshalltown |
Marshall |
Iowa |
Antonio Ramirez Sanchez |
Genoveva Alvizu Hernandez |
Signed |
589 |
2023-01-16 10:18 |
Anonymous (not verified) |
174.130.20.253 |
HCS Trucking LLC |
403 Date St Schleswig, IA 51461 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-16 |
Jamie Hedstrom |
hedstromcrane@gmail.com |
Schleswig |
Crawford |
Iowa |
Noah Hedstrom |
Landa Hedstrom |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Jamie Hedstrom |
hedstromcrane@gmail.com |
owner |
Schleswig |
Crawford |
Iowa |
Noah Hedstrom |
Landa Hedstrom |
Signed |
609 |
2023-02-22 18:56 |
Anonymous (not verified) |
94.188.205.174 |
Roman construction |
3214 se 20th st, Des Moines, Iowa, 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. |
(2) I decline to reject the employer’s liability coverage. |
2023-02-22 |
Jonathan roman |
romanconstruction21@outlook.com |
Des moines |
Polk |
Iowa |
Jonathan Roman |
Perla Roman |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Jonathan Roman |
romanconstruction21@outlook.com |
Owner |
Des moines |
Polk |
Iowa |
Jonathan roman |
Perla roman |
Signed |
610 |
2023-02-23 16:19 |
Anonymous (not verified) |
94.188.207.228 |
Glorious tile service llc |
3905 NE 6th st Ankeny IA 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. |
2023-02-23 |
Heileselaisi unguec |
glorioustile6@gmail.com |
Ankeny |
United States |
IOWA |
Robert duku |
Abraham deng |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Heileselaisi unguec |
glorioustile6@gmail.com |
Owner llc member |
Ankeny |
United States |
Iowa |
Robert duku |
Abraham deng |
Signed |
611 |
2023-02-23 16:27 |
Anonymous (not verified) |
94.188.207.224 |
Sandra unguec |
3905 NE 6th st Ankeny IA 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. |
2023-02-23 |
Sandra unguec |
glorioustile6@gmail.com |
Ankeny |
United States |
Iowa |
Robert duku |
Abraham deng |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Sandra unguec |
glorioustile6@gmail.com |
Wife of the owner |
Ankeny |
United States |
Iowa |
Robert duku |
Abraham deng |
Signed |
640 |
2023-03-28 18:28 |
Anonymous (not verified) |
94.188.205.174 |
SM TILE DESIGN LLC |
670 Daybreak dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-28 |
Samir Mulalic |
smtiledesign@gmail.com |
Waukee |
Iowa |
United States |
Samir Mulalic |
Saneta Dzankovic |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Samir Mulalic |
smtiledesign@gmail.com |
Owner |
Waukee |
Iowa |
United States |
Samir Mulalic |
Saneta Dzankovic |
Signed |
647 |
2023-04-04 11:51 |
Anonymous (not verified) |
94.188.207.225 |
Ibarra's Construction LLC |
4125 56th Street Des Moines IA 50310 |
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. |
2023-04-04 |
Serafin Orendain Rivera |
serafinorivera334@gmail.com |
Des Moines |
Polk |
Iowa |
Saul Orendain |
Maricela Pillado |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Matt Thompson |
mthompson@urscompliance.com |
Agent |
Minneapolis |
Hennepin County |
MN |
Maricela Pillado |
Saul Orendain |
Signed |
659 |
2023-04-21 13:58 |
Anonymous (not verified) |
94.188.205.168 |
Streamline Plumbing LLC |
1513 Nw 8th St Grimes, IA 50111 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2023-04-21 |
Benjamin Molloy |
slplumbing.llc@gmail.com |
Grimes |
IA |
United States |
Christine Darnell |
Steven Perona |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Benjamin Molloy |
slplumbing.llc@gmail.com |
owner |
Grimes |
IA |
United States |
Christine Darnell |
Steven Perona |
Signed |
719 |
2023-07-31 16:00 |
Anonymous (not verified) |
94.188.205.175 |
Krupa-1 LLC |
128 Main 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. |
2023-07-31 |
Maher Patel |
deckerhotel008@gmail.com |
Dodgeville |
Iowa |
WI |
Mitch Schaller |
Susan Cox |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Mihir Patel |
deckerhotel008@gmail.com |
Owner/ Partner |
Fitchberg |
Dane |
WI |
Susan Cox |
Mitch Schaller |
Signed |