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Rejection of Workers' Compensation or Employers' Liability Coverage

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# Submitted User IP address Name of Corporation: Address of Corporation Home Office: Statement 1 Agreement: Statement 2 Agreement: Statement 3 Agreement: Statement Agreement: Check Either Alternative (1) or (2): Date: Full Name of Individual: Email: City of Residence: County of Residence: State of Residence: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Agreement: Alternative Selection: Full Name of Authorized Agent: Email of Authorized Agent: Relationship to Corporation of Authorized Agent: City of Residence: County of Residence: State: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Indication:
547 2022-09-29 09:04 Anonymous (not verified) 208.126.212.128 City of Leland 316 Walnut St., PO Box 127, Leland, IA 50453 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. 2022-09-29 Ken Steil leland@wctatel.net Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed (1) The corporation rejects the employers’ liability coverage. Dawn Arispe leland@wctatel.net City of Leland City Clerk Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed
548 2022-09-29 09:06 Anonymous (not verified) 208.126.212.128 City of Leland 316 Walnut St., PO Box 127, Leland, IA 50453 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. 2022-09-29 Rex Johnson rexr@wctatel.net Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed (1) The corporation rejects the employers’ liability coverage. Dawn Arispe leland@wctatel.net City of Leland City Clerk Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed
549 2022-09-29 09:08 Anonymous (not verified) 208.126.212.128 City of Leland 316 Walnut St., PO Box 127, Leland, IA 50453 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. 2022-09-29 Jesse O'Toole jesseotoole7@gmail.com Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed (1) The corporation rejects the employers’ liability coverage. Dawn Arispe leland@wctatel.net City of Leland City Clerk Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed
550 2022-09-29 09:10 Anonymous (not verified) 208.126.212.128 City of Leland 316 Walnut St., PO Box 127, Leland, IA 50453 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. 2022-09-29 Russell Leitz rkleitz@wctatel.net Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed (1) The corporation rejects the employers’ liability coverage. Dawn Arispe leland@wctatel.net City of Leland City Clerk Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed
346 2021-10-14 13:54 Anonymous (not verified) 75.162.50.106 Dawn's Daycare & Educational Program 360 NW Walnut Ave, Earlham, Iowa 50072 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-10-14 Dawn Lynnete Stonehocker daycare.dawn@gmail.com Earlham Madison Iowa Anne Marie Larson Alison Renae Werts Signed (1) The corporation rejects the employers’ liability coverage. Dawn Lynnette Stonehocker daycare.dawn@gmail.com Self Earlham Madison Iowa Anne Marie Larson Alison Renae Werts Signed
721 2023-08-01 09:24 Anonymous (not verified) 94.188.205.167 Dryseal Roofing and Construction 390 Olive St Martensdale, IA 50160 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-01 Travis Tibbits travistibbits@yahoo.com Martensdale Warren IA Hannah Marie Tibbits Chad David Walker Signed (1) The corporation rejects the employers’ liability coverage. Dawn Marie Tibbits Tibbits6@gmail.com Spouse Martensdale Warren IA Hannah Marie Tibbits Chad David Walker Signed
483 2022-06-02 08:28 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 Deb Sylvester judy@fullenkampins.com Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Deb Sylvester judy@fullenkampins.com Secretary / Treasurer Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed
657 2023-04-20 11:33 Anonymous (not verified) 94.188.205.177 Debra Higgins 201 Cedar st I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-04-20 Debra Higgins diggs0519@icloud.com Slater IA United States Howard Higgins Howard Higgins Signed (1) The corporation rejects the employers’ liability coverage. Debra Higgins diggs0519@icloud.com owner Slater IA United States Howard Higgins Howard Higgins Signed
658 2023-04-20 11:39 Anonymous (not verified) 94.188.205.167 Old Pros Consulting Inc 201 Cedar St Slater Iowa 50244 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. 2023-04-20 Debra Higgins diggs0519@icloud.com Slater IA United States Howard Higgins Howard Higgins Signed (1) The corporation rejects the employers’ liability coverage. Debra Higgins diggs0519@icloud.com owner Slater IA United States Howard Higgins Howard Higgins Signed
301 2021-08-04 10:05 Anonymous (not verified) 63.142.48.170 Vision Homes Inc 2566 Ivanhoe Rd. 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. 2021-07-02 DeeAnn Nejdl chucknejdl@gmail.com Cedar Rapids Linn Iowa Melanie Heitman Dan Lillis Signed (1) The corporation rejects the employers’ liability coverage. DeeAnn Nejdl chucknejdl@gmail.com Owner Cedar Rapids Linn Iowa Melanie Heitman Dan Lillis 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
841 2023-12-18 16:28 Anonymous (not verified) 94.188.205.168 Dennis Clement 203 Astor St I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-18 Dennis Clement haight0929@gmail.com Des Moines Polk IA Amanda Thompson Brandi Haight Signed (1) The corporation rejects the employers’ liability coverage. Dennis Clement haight0929@gmail.com none Des Moines polk IA Brandi Haight Amanda Thompson Signed
821 2023-11-17 13:30 Anonymous (not verified) 94.188.207.230 ABC LOCK INC. 2209 2nd Ave S. P.O. Box 433 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-17 Dennis Diekhuis keyman@cltel.net Clear Lake United States Iowa Dennis Diekhuis Dennis Diekhuis Signed (1) The corporation rejects the employers’ liability coverage. Dennis Diekhuis keyman@cltel.net Owner Clear lake United States Iowa Dennis Diekhuis Dennis Diekhuis Signed
872 2024-01-26 10:28 Anonymous (not verified) 94.188.205.177 Sole proprietor- Dennis R. Oliver dba Olivers Oasis Communications 150 Spring Valley Ct. Springtown, TX 76082 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. 2024-01-26 Dennis Reeves Oliver doliversoasis@aol.com Springtown Parker Texas Helen Frances Steil John Kevin Steil Signed (1) The corporation rejects the employers’ liability coverage. Dennis Reeves Oliver doliversoasis@aol.com Self Springtown Parker TX Helen Frances Steil John Kevin Steil Signed
86 2020-06-03 17:56 Anonymous (not verified) 75.162.69.231 Blackford Foundations Inc 501 SW Franklin Dr, Ankeny, IA 50023 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-05-01 Denny Lee Blackford blackfordfoundations@gmail.com Ankeny Polk Iowa Saree Luce Ricky Eatwell Signed (1) The corporation rejects the employers’ liability coverage. Denny Lee Blackford blackfordfoundations@gmail.com Secretary Ankeny Polk Iowa Saree Luce Ricky Eatwell Signed
65 2020-04-20 13:37 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, P.O. Box 609 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. (1) I reject the employers’ liability coverage. 2020-04-01 Denny Walker jennifer@walkerinsuranceia.com West Okoboji Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Denny Walker jennifer@walkerinsuranceia.com Board Member West Okoboji Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
772 2023-09-18 12:52 Anonymous (not verified) 94.188.207.224 Wallenburg Trucking LLC 911 8th Street SW 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. 2023-09-18 Heath Ryan Wallenburg heathwallenburg@gmail.com Rock Valley IA United States Dustin Van Beek Lucas Van Engen Signed (1) The corporation rejects the employers’ liability coverage. Deric Hill d.hill@joemorten.com Insurance Sioux City NE Dakota County Nebraska Dustin Van Beek Lucas Van Engen Signed
76 2020-05-04 10:24 Anonymous (not verified) 173.191.207.202 Tim Fitzgerald Mechanical Services, Inc. 724 1st Ave W - Dyersville, IA 52040 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-24 Tim Fitzgerald jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent-English Insurance Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
108 2020-08-19 09:39 Anonymous (not verified) 184.80.177.137 Michelle's Vocational Placement LLC 2642 Farragut Pl., Davenport, IA 52804 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-08-18 Tara Rommel jheims@engish-insurance.com Davenport Scott Iowa Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed
129 2020-10-30 11:23 Anonymous (not verified) 184.80.177.137 Haberdash Outfitters, Inc. 109 1st Ave East - Dyersville, IA 52040 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-10-27 Jennifer Recker jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
384 2022-01-06 16:01 Anonymous (not verified) 184.80.177.137 Top R Farms 1199 Woodland Drive - Dyersville, IA 52040 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-06 Robert Fangmann jheims@english-insurance.com Dyersville Dubuque IA Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons jheims@english-insurance.com agent Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed
396 2022-02-01 10:03 Anonymous (not verified) 184.80.177.137 LKB Holdings, LLC P.O. box 313 - Monona, Ia 52159 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-29 Kandi Gillitzer jheims@english-insurance.com Monoa Clayton Iowa Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com self Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
413 2022-02-23 16:31 Anonymous (not verified) 184.80.177.137 T-Rex Hospitality LLC, DBA FUSE 120 Twin Steeples Circle, Dyersville Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-23 Tara Rahe jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
448 2022-04-19 15:15 Anonymous (not verified) 184.80.177.137 Andrew Lemke DBA: TAP Fabrication 27214 218th Street, Earlville, IA 52041 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-08 Andrew Lemke jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
515 2022-07-19 10:06 Anonymous (not verified) 184.80.177.137 Mom Clean, LLC 4 East 3rd Street - Earlville, IA 52041 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-18 Morgan Lahr dparsons@english-insurance.com Dyersville Delaware IA Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com self Dyersville Dubuque IA Derrick Parsons Joyce Heims Signed
541 2022-09-23 13:13 Anonymous (not verified) 184.80.177.137 Tim & Lori Daly 25430 New Vienna Rd - Farley, IA 52046 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-23 Tim Daly jheims@english-insurance.com Dyersville Dubuque IA Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque IA Derrick Parsons Joyce Heims Signed
741 2023-08-15 12:03 Anonymous (not verified) 94.188.205.176 The Ritz Restaurant, LLC 232 1st Ave E - Dyersville, IA 52040 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-11 Megan Engstrom jheims@english-insurance.com Dyersville Dubuque IA Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons jheims@english-insurance.com self Dyersville DUbuque IA Joyce Heims Derrick Parsons Signed
742 2023-08-15 12:06 Anonymous (not verified) 94.188.205.175 The Ritz Restaurant, LLC 232 1st Ave E - Dyersville, IA 52040 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-11 Dan Engstrom jheims@english-insurance.com Dyersville Dubuque IA Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons jheims@english-insurance.com self Dyersville IA IA Joyce Heims Derrick Parsons Signed
823 2023-11-20 14:04 Anonymous (not verified) 94.188.205.169 CDNE, Inc. 311 E. Alta Vistta 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. 2023-11-20 Craig Allen Payne Craig.Payne@indianhills.edu Ottumwa Wapello Iowa Erin Elizabeth Payne Nathan Thomas Payne Signed (1) The corporation rejects the employers’ liability coverage. Desirae Lynn Payne desip845@gmail.com Spouse Ottumwa Wapello Iowa Erin Elizabeth Payne Nathan Thomas Payne Signed
57 2020-04-10 11:14 Anonymous (not verified) 136.34.78.83 KALONA SALES BARN, INC. 191 9TH STREET; KALONA, IA 52247 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. 2020-04-07 DEVIN MULLET LMULLET@KALONASALESBARN.COM KALONA WASHINGTON IOWA ALANA MULLET ROCHELLE MULLET Signed (1) The corporation rejects the employers’ liability coverage. DEVIN MULLET LMULLET@KALONASALESBARN.COM OWNER KALONA WASHINGTON IOWA ALANA MULLET ROCHELLE MULLET Signed
712 2023-07-24 12:34 Anonymous (not verified) 94.188.205.168 BOG Roofing 3768 Deerbrook 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. 2023-07-24 Devon Booton devonboot1973@gmail.com Bettendorf Iowa United States Viviana Gonzalez Shannon Wolever Signed (1) The corporation rejects the employers’ liability coverage. Devon Booton devonboot1973@gmail.com Self Bettendorf Iowa United States Viviana Gonzalez Shannon Wolever Signed
362 2021-11-16 11:20 Anonymous (not verified) 63.227.65.43 F&H Aluminum, Inc. 101 E. Corporate Drive Charles City, Iowa 50616 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-11-16 DeWayne Ferch fhaluminum@netconx.net Kensett Worth Iowa Tom Stephany Amanda Korenberg Signed (1) The corporation rejects the employers’ liability coverage. DeWayne Ferch fhaluminum@netconx.net President Kensett Worth Iowa Tom Stephany Amanda Korenberg Signed
582 2022-12-09 11:26 Anonymous (not verified) 74.84.79.78 Diamond Does It LLC 3945 38th St. 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. 2022-01-01 Daimond Martinez diamonddoesitdsm@gmail.com Des Moines Polk Iowa Michael O'Conner Ron Rand Signed (1) The corporation rejects the employers’ liability coverage. Diamond Martinez diamonddoesitdsm@gmail.com Owner Des Moines Polk Iowa Michael O'Conner Ron Rand 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
215 2021-03-29 07:58 Anonymous (not verified) 173.18.193.51 Lee County Fair, Inc PO Box 179 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. 2021-03-05 Dillon Benner judy@fullenkampins.com ARgyle IA United States Lindsey Lampe Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Dillon Benner judy@fullenkampins.com Board Member Argyle IA United States Lindsey Lampe Judy Moeller Signed
116 2020-09-11 11:42 Anonymous (not verified) 69.57.22.68 Brush and Weed Control Specialists, Inc. 1108 230th Street - Algona, IA 50511 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-11 Ruth Jean Lindgren bwcontrol@netamumail.com Algona Kossuth Iowa James Black Katie Melvin Signed (1) The corporation rejects the employers’ liability coverage. Donald H Reffer bwcontrol@netamumail.com President and General Manager Algona Kossuth Iowa James Black Katie Melvin 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
55 2020-04-06 16:25 Anonymous (not verified) 74.221.44.37 Steele Land & Livestock, Inc 1040 190th St, Anita, IA 50020 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. 2020-04-06 Doug Steele dsteele@midlands.net Anita Adair Iowa Sheryl Leonard Cheryl Ellis Signed (1) The corporation rejects the employers’ liability coverage. Doug Steele dsteele@midlands.net President Anita Adair Iowa Sheryl Leonard Cheryl Ellis Signed
622 2023-03-08 13:40 Anonymous (not verified) 94.188.207.226 DDD Construction 624 west maple P.O.164 Allerton 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. 2023-03-08 Douglas Dean Downs tripledconstruction@hotmail.com ALLERTON IA United States June Lynette Downs William Lee Downs Signed (1) The corporation rejects the employers’ liability coverage. Douglas Dean Downs tripledconstruction@hotmail.com Coowner ALLERTON IA United States June Lynette Downs William Lee Downs Signed
715 2023-07-26 11:23 Anonymous (not verified) 94.188.207.226 Lampe Appliance Service, Inc 210 29th St NE, Cedar Rapids, IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-26 Douglas James Lampe lampeappliance@gmail.com Cedar Rapids Linn IA John Kenneth Lampe Jared Joshua Lampe Signed (1) The corporation rejects the employers’ liability coverage. Douglas James Lampe lampeappliance@gmail.com President CEDAR RAPIDS IA United States John Kenneth Lampe Jared Joshua Lampe Signed
716 2023-07-26 11:27 Anonymous (not verified) 94.188.207.228 Lampe Appliance Service, Inc 210 29th St NE, Cedar Rapids, IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-26 John Kenneth Lampe lampeappliance@gmail.com CEDAR RAPIDS Linn Iowa Douglas James Lampe Jared Joshua Lampe Signed (1) The corporation rejects the employers’ liability coverage. Douglas James Lampe lampeappliance@gmail.com President CEDAR RAPIDS IA United States John Kenneth Lampe Jared Joshua Lampe Signed
717 2023-07-26 11:31 Anonymous (not verified) 94.188.207.230 Lampe Appliance Service, Inc 210 29th St NE, Cedar Rapids, IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-26 Jared Joshua Lampe lampeappliance@gmail.com CEDAR RAPIDS Linn Iowa Douglas James Lampe John Kenneth Lampe Signed (1) The corporation rejects the employers’ liability coverage. Douglas James Lampe lampeappliance@gmail.com President CEDAR RAPIDS Linn United States John Kenneth Lampe Jared Joshua Lampe Signed
700 2023-06-22 11:03 Anonymous (not verified) 94.188.207.229 WIT Systems Corporation 313 Brentwood Dr NE, Cedar Rapids, IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-22 DOUGLAS K WILLIAMS dkwilliams@witsystems.com Cedar Rapids IA Linn CT Patrick Gavin Kaley Gavin Signed (1) The corporation rejects the employers’ liability coverage. DOUGLAS K WILLIAMS dkwilliams@witsystems.com President CEDAR RAPIDS IA United States Patrick Gavin Kaley Gavin Signed
542 2022-09-26 19:26 Anonymous (not verified) 45.78.142.139 Doyle Vondrak Trucking 315 Vermont Avenue, Kingsley, Iowa 51028 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. 2022-09-26 Doyle P Vondrak dpvondrak@wiatel.net Kingsley Plymouth Iowa Jayne R Vondrak Jesse M Vondrak Signed (1) The corporation rejects the employers’ liability coverage. Doyle P Vondrak dpvondrak@wiatel.net self-employed; single employee Kingsley Plymouth Iowa Jayne R Vondrak Jesse M Vondrak Signed
968 2024-05-02 13:34 Anonymous (not verified) 94.188.207.227 Harman Construction, LLC 103 NW 6TH ST, POCAHONTAS, IA 50574 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 DRAKE HARMAN harmanconstructionllc@gmail.com POCAHONTAS POCAHONTAS IOWA JESSE NEWGARD TRACY GROTHAUS Signed (1) The corporation rejects the employers’ liability coverage. DRAKE HARMAN harmanconstructionllc@gmail.com OWNER POCAHONTAS POCAHONTAS IOWA JESSE NEWGARD TRACY GROTHAUS Signed
495 2022-06-08 13:07 Anonymous (not verified) 173.31.148.43 OKOBOJI PERFORMING ARTS 97 WOODLIN DR MILFORD, IA 51351 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. 2022-06-08 DREW DUNCAN DREW@OKOBOJIPERFORMINGARTS.COM LINCOLN LANCASTER NE JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The corporation rejects the employers’ liability coverage. DREW DUNCAN DREW@OKOBOJIPERFORMINGARTS.COM SELF LINCOLN LANCASTER NE JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
724 2023-08-02 16:09 Anonymous (not verified) 94.188.207.223 Magnussen Bros Inc 1945 560th Street, Newell, IA 50568 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-02 Duane Magnussen dcmag@ncn.net Newell Buena Vista Iowa Jared Brashears Katie Gunkelman Signed (1) The corporation rejects the employers’ liability coverage. Duane Magnussen ncmag@ncn.net Owner Newell Buena Vista IA Jared Brashears Katie Gunkelman Signed
294 2021-07-27 14:10 Anonymous (not verified) 173.19.179.111 MILFORD MECHANICAL INC 1607 L AVE MILFORD, IA 51351 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. 2021-06-14 DUSITN BOER joel@walkerinsuranceia.com MILFORD DICKINSON IOWA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The corporation rejects the employers’ liability coverage. DUSTIN BOER joel@walkerinsuranceia.com PRESIDENT MILFORD DICKINSON IOWA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
725 2023-08-02 17:25 Anonymous (not verified) 94.188.207.225 Furever Friends Rescue of Appanoose, Inc 19507 Hwy 2, Centerville, Iowa 52544 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-02 Dustin Cain Bozwell dcbozwell@gmail.com Centerville Appanoose Iowa Kimberly Stonehouse Jennifer Appler Signed (1) The corporation rejects the employers’ liability coverage. Dustin Bozwell dcbozwell@gmail.com President Centerville Appanoose Iowa Kimberly Stonehouse Jennifer Appler Signed
273 2021-06-08 12:34 Anonymous (not verified) 40.135.3.146 Gordinier Construction Inc 9555 SE 6th Ave, Runnells IA 50237 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 Dustin Gordinier gordinierconstruction@gmail.com Runnells Polk IA Robert Simmons Joe Meyers Signed (1) The corporation rejects the employers’ liability coverage. Dustin Gordinier gordinierconstruction@gmail.com Self Runnells Polk IA Robert Simmons Joe Meyers Signed