437 |
2022-03-29 14:03 |
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. |
2022-03-29 |
Mersad Bosnic |
mersadbosnic@yahoo.com |
Urbandale |
Polk |
Iowa |
Mersad Bosnic |
Andy Swanson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andy Swanson |
sanienterprise14@gmail.com |
Director of Operations |
Granger |
Dallas |
Iowa |
Andrew Swanson |
Sandro Tadic |
Signed |
142 |
2020-12-02 09:39 |
Anonymous (not verified) |
208.90.15.53 |
Humboldt Community Daycare, Inc. DBA Kiddie Cats Childcare and Learning Center |
P.O. Box 93 Dakota City, Ia 50529 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-02 |
Angelique Berry |
dcity@goldfieldaccess.net |
Algona |
Kossuth |
Iowa |
Ross Sleiter |
Scott Curran |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Angelique Berry |
dcity@goldfieldaccess.net |
Secretary/Treasurer |
Algona |
Kossuth |
Iowa |
Ross Sleiter |
Scott Curran |
Signed |
170 |
2021-01-26 12:23 |
Anonymous (not verified) |
74.84.91.178 |
Sunset Ridge Winery LLC |
12615 Highway 52 North, Dubuque, IA 52002 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-07 |
Ann Bonnette |
jbonnette@yahoo.com |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ann Bonnette |
jbonnette@yahoo.com |
Officer |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
585 |
2022-12-15 20:32 |
Anonymous (not verified) |
192.110.196.132 |
Maywood Enterprises, Inc. |
28345 Highway 52, Bellevue, IA 52031 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-12-15 |
Ann L Wachtel |
annw@financepro123.com |
Bellevue |
Jackson |
Iowa |
Katie Laban |
Jeffrey Laban |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ann L Wachtel |
annw@financepro123.com |
President |
Bellevue |
Jackson |
IA |
Katie Laban |
Jeffrey Laban |
Signed |
645 |
2023-03-31 08:55 |
Anonymous (not verified) |
94.188.205.166 |
3Fitt Life, Inc. |
28345 Highway 52, Bellevue, IA 52031 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-31 |
Ann L Wachtel |
annw@3fitt.com |
Bellevue |
Jackson |
Iowa |
Jeff Laban |
Katie Laban |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ann L Wachtel |
annw@3fitt.com |
President |
Bellevue |
Jackson |
Iowa |
Jeff Laban |
Katie Laban |
Signed |
537 |
2022-09-20 09:01 |
Anonymous (not verified) |
173.20.206.50 |
Accent Painting LLC |
613 Locust ST |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-09-20 |
Anthony Gilbert Gasco |
accentpainting@yahoo.com |
La Porte City |
Blackhawk |
Iowa |
Arthur Rudolf Gasco |
Aurora Jealee Gasco |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Anthony Gilbert Gasco |
accentpainting@yahoo.com |
Owner |
La Porte City |
Blackhawk |
Iowa |
Arthur Rudolf Gasco |
Aurora Jealee Gasco |
Signed |
956 |
2024-04-12 14:23 |
Anonymous (not verified) |
205.221.255.62 |
All things power wash ATP LLC |
2730 Lafayette, Sioux City, IA 51104 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-12 |
Anthony Rowe |
allthingspowerwash4usiouxcity@gmail.com |
Sioux City |
Woodbury |
Iowa |
Franzis Rios |
Tamara Bawi |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Anthony Rowe |
allthingspowerwash4usiouxcity@gmail.com |
Owner |
Sioux City |
Woodbury |
Iowa |
Franzis Rios |
Tamara Bawi |
Signed |
185 |
2021-02-23 15:16 |
Anonymous (not verified) |
173.29.151.168 |
TONY V'S PAINTING |
2316 CRESCENT AVE DAVENPORT, IA 52804 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-23 |
ANTHONY VANCE |
ANTHONYJV1977@GMAIL.COM |
DAVENPORT |
SCOTT |
IA |
TONY BURKHART |
RICHARD MILLER-VANCE |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
ANTHONY VANCE |
ANTHONYJV1977@GMAIL.COM |
OWNER |
DAVENPORT |
SCOTT |
IA |
TONY BURKHART |
RICHARD MILLER-VANCE |
Signed |
644 |
2023-03-31 08:47 |
Anonymous (not verified) |
94.188.205.175 |
HDEZ, LLC |
7500 Bloomfield Rd, Lot 91, Des Moines, IA 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-31 |
Antonio Rosales |
tonyh873@gmail.com |
Des Moines |
Polk |
Iowa |
Ronald Barton |
Scott Grimm |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Antonio Rosales |
tonyh873@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Ronald Barton |
Scott Grimm |
Signed |
904 |
2024-02-28 06:52 |
Anonymous (not verified) |
94.188.205.167 |
Monarca General Builders LLC. |
551 Martin Rd Waterloo Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-28 |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
President |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
905 |
2024-02-28 11:47 |
Anonymous (not verified) |
94.188.207.228 |
Monarca General Builders LLC |
551 Martin Rd Waterloo Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-01 |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
Presidente |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
157 |
2021-01-06 15:53 |
Anonymous (not verified) |
216.81.153.249 |
Al's Inc DWB CW&T |
1509 Richland Drive, Storm Lake, IA 5058 |
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. |
2020-12-29 |
April Coleman |
NONE@GMAIL.COM |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
April Coleman |
None@gmail.com |
Owner |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
526 |
2022-08-17 11:16 |
Anonymous (not verified) |
173.27.233.86 |
Bradens Roofing and Construction Llc |
2450 Hart Avenue |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-08-17 |
Arsenio Vargas Velazquez |
avargas409@gmail.com |
Des Moines |
polk |
Iowa |
Julissa Dionicio |
Jennifer Dionicio |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Arsenio Vargas Velazquez |
avargas409@gmail.com |
owner |
Des Moines |
Polk |
Iowa |
Julissa Dionicio |
Jennifer Dionicio |
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 |
831 |
2023-12-06 17:04 |
Anonymous (not verified) |
94.188.205.167 |
PHOENIX CONSTRUCTION LLC |
2219 E 13th St Des Moines, IA 50316 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-02 |
JUAN PABLO GUTIERREZ LEON |
jpgutierrez9000@yahoo.com |
Des Moines |
IA |
IA |
DAISY VASQUEZ |
Graciela Rodriguez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
arturo salgado |
fortworth@aksinsurance.com |
insured |
irving |
TX |
TX |
DAISY VASQUEZ |
DAISY VASQUEZ |
Signed |
834 |
2023-12-13 08:35 |
Anonymous (not verified) |
94.188.207.228 |
PHOENIX CONSTRUCTION LLC |
2219 E 13TH ST DES MOINES, IA 50316 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-13 |
JUAN PABLO GUTIERREZ LEON |
jpgutierrez9000@yahoo.com |
DES MOINES |
IA |
IA |
DAISY VASQUEZ |
GRACIELA RODRIGUEZ |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
ARTURO SALGADO |
commercial@aksinsurance.com |
Insured |
Irving |
TX |
TX |
DAISY VASQUEZ |
GRACIELA RODRIGUEZ |
Signed |
642 |
2023-03-30 09:56 |
Anonymous (not verified) |
94.188.205.174 |
Adamantine Spine Moving |
2726 Independence Road Iowa City, Iowa 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. |
2023-03-30 |
John Clifford Wallace |
cliff.wallace@spinemoving.com |
Des Moines |
Polk |
IA |
Taylor Christian Roth |
Ashley Anne Koch |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ashley Anne Koch |
ashley.koch@spinemoving.com |
HR, Safety and Compliance Manager |
Des Moines |
Polk |
Iowa |
Taylor Christian Roth |
John Clifford Wallace |
Signed |
643 |
2023-03-30 09:58 |
Anonymous (not verified) |
94.188.205.175 |
Adamantine Spine Moving |
2726 Independence Rd., 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. |
2023-03-30 |
Emily Wallace |
emily.wallace@spinemoving.com |
Des Moines |
Polk |
Iowa |
John Wallace |
Ashley Koch |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ashley Koch |
ashley.koch@spinemoving.com |
Human Resources Manager |
West Des Moines |
Polk |
Iowa |
John Wallace |
Taylor Roth |
Signed |
845 |
2024-01-02 09:03 |
Anonymous (not verified) |
94.188.205.169 |
American Tree Service LLC |
416 S Kiel Street, Holstein, IA 51025 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-02 |
Austin Thevenot |
americantreeservice03@gmail.com |
Holstein |
Ida |
Iowa |
Jared Brashears |
Katie Gunkelman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Austin Thevenot |
americantreeservice03@gmail.com |
Owner |
Holstein |
Ida |
Iowa |
Jared Brashears |
Katie Gunkelman |
Signed |
982 |
2024-05-10 19:06 |
Anonymous (not verified) |
94.188.207.228 |
Revella Salon and Spa |
509 Second 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. |
2024-05-10 |
Bailey Roeder |
roeder428@gmail.com |
Ida Grove |
Ida |
Iowa |
Dalton Hemer |
Fina Roeder |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bailey Roeder |
roeder428@gmail.com |
Myself |
Ida Grove |
Ida |
Iowa |
Dalton Hemer |
Fina Roeder |
Signed |
784 |
2023-10-09 13:09 |
Anonymous (not verified) |
94.188.205.177 |
SEHIC G&S LLC |
4201 62nd st apt 4 Urbandale Iowa 50322 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-09 |
Bajro Sehic |
kalesija20@gmail.com |
Urbandale |
Polk |
Iowa |
Bajro sehic |
Bajro sehic |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bajro sehic |
kalesija20@gmail.com |
Owner |
Urbandale |
Polk |
Iowa |
Bajro sehic |
Bajro Sehic |
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 |
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 |
687 |
2023-06-16 07:59 |
Anonymous (not verified) |
94.188.207.230 |
Benjamin Campos Rojas |
4024 52nd Street Des Moines, Iowa 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. |
2023-06-16 |
Benjamin Campos Rojas |
caya05rojas@gmail.com |
Des Moines |
Polk |
Iowa |
Erica Antonio Maya |
Ana Antonio Maya |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Benjamin Campos Rojas |
caya05rojas@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Erica Antonio Maya |
Ana Antonio Maya |
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 |
630 |
2023-03-21 21:32 |
Anonymous (not verified) |
94.188.205.169 |
S & O Builders, LLC |
201 NW 10th Circle, 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. |
(1) I reject the employers’ liability coverage. |
2023-03-21 |
Benjamin Olson |
sandobuilders@gmail.com |
Grimes |
IA |
IA |
Brad Fasse |
Nate Estes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Benjamin Olson |
sandobuilders@gmail.com |
Co-Owner |
Grimes |
IA |
IA |
Brad Fasse |
Nate Estes |
Signed |
146 |
2020-12-22 08:48 |
Anonymous (not verified) |
207.155.115.120 |
Kafer Lawn Care |
206 frentress dr 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. |
2020-12-22 |
Benjamin Terry Hayes |
benhayes1800@gmail.com |
Epworth |
Dubuque |
IA |
Adam Kafer |
Jeffery Sisler |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Benjamin Terry Hayes |
benhayes1800@gmail.com |
Owner |
Epworth |
Dubuque |
IA |
Adam Kafer |
Jeffery Sisler |
Signed |
771 |
2023-09-17 13:33 |
Anonymous (not verified) |
94.188.205.176 |
Apex Landlord Services LLC |
429 Shetland Dr NW, Cedar Rapids, IA 52405 |
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. |
2023-09-17 |
Benjamin Walhood |
info@apexlandlordservices.com |
Cedar Rapids |
Linn |
Iowa |
Justin Goebel |
Jennifer Goebel |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Benjamin Walhood |
info@apexlandlordservices.com |
Managing Member |
Cedar Rapids |
Linn |
Iowa |
Justin Goebel |
Jennifer Goebel |
Signed |
107 |
2020-08-04 13:42 |
Anonymous (not verified) |
97.64.131.90 |
BNR Construction INC |
210 4th St Orient, IA 50858 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-08-04 |
Bennie Shinn |
bnrconstllc@gmail.com |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bennie Shinn |
bnrconstllc@gmail.com |
President |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
111 |
2020-08-25 14:37 |
Anonymous (not verified) |
204.155.61.217 |
BNR Construction INC |
210 4th St Orient,Ia 50858 |
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. |
2020-07-15 |
Bennie Shinn |
bnrconstructllc@gmail.com |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bennie Shinn |
bnrconstructllc@gmail.com |
President |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
112 |
2020-08-26 10:18 |
Anonymous (not verified) |
97.64.131.90 |
BNR Construction INC |
210 4th St Orient, IA 50858 |
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. |
2020-07-15 |
Bennie Shinn |
bnrconstllc@gmail.com |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bennie Shinn |
bnrconstllc@gmail.com |
President |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
318 |
2021-08-23 11:00 |
Anonymous (not verified) |
216.51.164.69 |
Z Homes and Realty Inc |
1324 3rd Ave SE Sioux Center IA 51250 |
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. |
2021-05-19 |
Beverly Zwart |
mbzwrt@mtcnet.net |
Sioux Center |
Sioux |
IA |
Lisa Dykstra |
Blake Kruger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Beverly Zwart |
mbzwrt@mtcnet.net |
Owner |
Sioux Center |
Sioux |
IA |
Lisa Dykstra |
Blake Kruger |
Signed |
482 |
2022-06-02 08:25 |
Anonymous (not verified) |
173.18.193.51 |
Wever Fire Association |
1692 354th Avenue, Wever, Iowa 52658 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-24 |
Bill Brookhiser |
judy@fullenkampins.com |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bill Brookhiser |
judy@fullenkampins.com |
Board Member |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
337 |
2021-09-16 21:28 |
Anonymous (not verified) |
173.17.8.56 |
Hutch's Parking Lot Sweeping Inc. |
5235 Jennifer Dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-16 |
Bill E Hutchinson |
btnwhutch@aol.com |
Pleasant Hill |
Iowa |
Iowa |
Tracy Hutchinson |
Nic Hutchinson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bill E Hutchinson |
btnwhutch@aol.com |
Same |
Pleasant Hill |
Iowa |
Iowa |
Tracy Hutchinson |
Nic Hutchinson |
Signed |
969 |
2024-05-02 16:15 |
Anonymous (not verified) |
94.188.205.175 |
Adamantine Spine Moving |
2726 Independence Rd 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. |
2024-05-02 |
John Clifford Wallace |
cliff.wallace@spinemoving.com |
Des Moines |
Polk |
Iowa |
John Thomas Wallace |
Amanda Root Wallace |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bill Hoke |
bill.hoke@spinemoving.com |
HR |
Des Moines |
Polk |
County |
Sarah Mannix |
Erika Banks |
Signed |
172 |
2021-01-26 19:02 |
Anonymous (not verified) |
173.17.8.56 |
Hutch's Parking Lot Sweeping |
5235 JENNIFER DR |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-26 |
Bill HUTCHINSON |
btnwhutch@aol.com |
PLEASANT HILL |
Iowa |
United States |
TRACY HUTCHINSON |
WHITNIE HUTCHINSON |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bill HUTCHINSON |
btnwhutch@aol.com |
Self |
PLEASANT HILL |
Iowa |
United States |
TRACY HUTCHINSON |
WHITNIE HUTCHINSON |
Signed |
965 |
2024-04-30 10:47 |
Anonymous (not verified) |
94.188.205.177 |
Billy Dudock |
148818 Argo Fay 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. |
2024-04-30 |
Billy Dudock |
mitzi@bruggemanlumber.com |
Thompson |
Carroll |
IL |
Roger Gibbs |
Mitzi Hoeger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Billy Dudock |
mitzi@bruggemanlumber.com |
Self |
Thompson |
Carroll |
Il |
Roger Gibbs |
Mitzi Hoeger |
Signed |
106 |
2020-07-27 12:12 |
Anonymous (not verified) |
206.125.132.254 |
Pacos Roofing Inc |
837 Lynkaylee Dr Waterloo, IA 50701 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-27 |
Blanca Garcia |
Pacosroofing@outlook.com |
Waterloo |
Black Hawk |
Iowa |
Kaitlin Schepers |
Sarah Whalen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Blanca Garcia |
Pacosroofing@outlook.com |
Owner |
Waterloo |
Black Hawk |
Iowa |
Kaitlin Schepers |
Sarah Whalen |
Signed |
804 |
2023-10-31 13:04 |
Anonymous (not verified) |
94.188.207.226 |
NeX Level Restoration LLC |
314 8th ST NW, Cedar Rapids, IA 52405 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-31 |
Bobby Caldwell SR |
blc5000@msn.com |
Cedar Rapids |
Linn |
IA |
Adam Feldmann |
Tarin Tanner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bobby Caldwell |
blc5000@msn.com |
Self |
Cedar Rapids |
Linn |
IA |
Adam Feldmann |
Tarin Tanner |
Signed |
562 |
2022-11-04 10:32 |
Anonymous (not verified) |
98.159.123.124 |
Alli-Center |
555 Cameron Way Unit 2 North Liberty Iowa 52317 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-11-04 |
Bonnie Seely |
bseely4@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Jonah C Seely |
Hannah Seely |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bonnie Seely |
bseely4@gmail.com |
Owner/Self |
Cedar Rapids |
Linn |
Iowa |
Jonah Seely |
Hannah Seely |
Signed |
587 |
2023-01-09 10:04 |
Anonymous (not verified) |
173.27.230.122 |
Hatfield Co Inc |
307 E 20th St Box 185 |
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. |
2023-01-09 |
Brenda Hatfield |
brenmarie137.bh@gmail.com |
Lovilia |
IA |
United States |
Jerry Griffin |
Dave Chesnut |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Boyle and Henderson |
joycem@boyleandhenderson.com |
Accountant |
Oskaloosa |
Marion |
Iowa |
Jerry Griffin |
Dave Chesnut |
Signed |
656 |
2023-04-19 10:46 |
Anonymous (not verified) |
94.188.205.174 |
Brad Anthony Logging LLC |
307 Commercial St, Strawberry Point IA 52076 |
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. |
2023-04-18 |
Brad Anthony |
banthony6487@gmail.com |
Strawberry Point |
Clayton |
Iowa |
Roger Gibbs |
Mitzi Hoeger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Anthony |
banthony6487@gmail.com |
Self |
Strawberry Point |
Clayton |
Iowa |
Mitzi Hoeger |
Roger Gibbs |
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 |
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 |
561 |
2022-11-03 11:24 |
Anonymous (not verified) |
96.31.21.117 |
Northwest 9 Inc. |
1512 Elmwood Ave. |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-11-03 |
Ethan Meyer |
ethanmeyer83@gmail.com |
ROCK RAPIDS |
Iowa |
United States |
Brad Meyer |
Trinda Meyer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Meyer |
nw9farm@gmail.com |
owner |
Rock Rapids |
IA |
United States |
Trinda Meyer |
Brad Meyer |
Signed |
862 |
2024-01-22 13:55 |
Anonymous (not verified) |
94.188.207.228 |
Emcubed Enterprises, Inc |
979 40th Ave, 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. |
2024-01-22 |
Bradley D Morrison |
brad@riverbendsignworks.com |
Moline |
Rock Island |
IL |
Richard Henning |
Kyle Sebben |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Morrison |
brad@riverbendsignworks.com |
Owner |
Moline |
Rock Island |
IL |
Richard Henning |
Kyle Sebben |
Signed |
233 |
2021-04-13 10:35 |
Anonymous (not verified) |
172.83.18.1 |
Skyway Inc |
7030 27th Way, 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. |
2021-03-06 |
Brad Thompson |
mary@skywaypropertyinspections.com |
Clear Lake |
Cerro Gordo |
Iowa |
Becky Plagge |
Deb Otto |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Thompson |
mary@skywaypropertyinspections.com |
Owner |
Clear Lake |
Cerro Gordo |
Iowa |
Becky Plagge |
Deb Otto |
Signed |
234 |
2021-04-13 10:37 |
Anonymous (not verified) |
172.83.18.1 |
Skyway Inc |
7030 27th Way, 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. |
2021-03-06 |
Mary Thompson |
mary@skywaypropertyinspections.com |
Clear Lake |
Cerro Gordo |
Iowa |
Becky Plagge |
Deb Otto |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Thompson |
mary@skywaypropertyinspections.com |
Owner |
Clear Lake |
Cerro Gordo |
Iowa |
Becky Plagge |
Deb Otto |
Signed |
245 |
2021-04-22 10:54 |
Anonymous (not verified) |
172.83.18.1 |
Skyway Inc |
7030 27th Way, 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. |
2021-04-22 |
Brad Thompson |
becky@fgains.com |
Clear Lake |
Cerro Gordo |
Iowa |
Debbie Otto |
Paxton Farmer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Thompson |
becky@fgains.com |
Owner |
Clear Lake |
Cerro Gordo |
Iowa |
Debbie Otto |
Paxton Farmer |
Signed |
246 |
2021-04-22 10:56 |
Anonymous (not verified) |
172.83.18.1 |
Skyway Inc |
7030 27th Way, 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. |
2021-04-22 |
Mary Thompson |
becky@fgains.com |
Clear Lake |
Cerro Gordo |
Iowa |
Debbie Otto |
Paxton Farmer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Thompson |
becky@fgains.com |
Owner |
Clear Lake |
Cerro Gordo |
Iowa |
Debbie Otto |
Paxton Farmer |
Signed |