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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:
597 2023-02-06 08:11 Anonymous (not verified) 107.121.104.18 Household Nanny 1357 Woolridge Dr., Coralville, IA 52241 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. 2023-02-06 Giselle Marie Statz Gisellestatz@gmail.com Coralville IA United States Jeffrey Peterson Casey Edwards Signed (1) The corporation rejects the employers’ liability coverage. Giselle Marie Statz gisellestatz@gmail.com Owner CORALVILLE Johnson Iowa Jeffrey Peterson Casey Edwards Signed
974 2024-05-06 08:02 Anonymous (not verified) 94.188.205.176 Milton Recycling & Roll Off Service LLC 1266 218 PL, Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-06 Glenn Kreuder kreuderfarms@yahoo.com Boone IA United States Amanda Krull Adam Krull Signed (1) The corporation rejects the employers’ liability coverage. Glenn Kreuder kreuderfarms@yahoo.com Member Boone IA United States Amanda Krull Adam Krull Signed
36 2020-01-31 14:59 Anonymous (not verified) 96.31.22.239 HOGMILE PORK LLC 2032 220TH ST INWOOD IOWA 51240 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. 2020-01-31 GLENN VANDEVEGTE glenvv@alliancecom.net INWOOD LYON IOWA LISA FABER ERIC TEGROOTENHUIS Signed (1) The corporation rejects the employers’ liability coverage. GLENN VANDEVEGTE glennvv@alliancecom.net self INWOOD LYON IOWA LISA FABER ERIC TEGROOTENHUIS Signed
348 2021-10-20 11:06 Anonymous (not verified) 97.116.100.220 Gonzalo construction LLC 5517 Brookdale Dr n apt 105 Brooklyn Park, mn 55443 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-10-20 Gonzalo Roman robles gonzaloconstructionmn@gmail.com Brooklyn park Hennepin Minnesora Gonzalo Roman robles Ashley Kraft Signed (1) The corporation rejects the employers’ liability coverage. Gonzalo Roman robles gonzaloconstruction@gmail.com Owner Brooklyn park Hennepin Minnesota Gonzalo Roman robles Ashley Kraft Signed
313 2021-08-19 10:28 Anonymous (not verified) 216.81.153.249 Bailey01 LLC 3020 S Cypress, Sioux City, IA 51106 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-19 Gordon Hagen gordonhagen1@outlook.com Sioux City Woodbury Iowa Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Gordon Hagen gordonhagen1@outlook.com Owner Sioux City Woodbury IA Jared Brashears Mary Jo Olthoff Signed
334 2021-09-14 16:24 Anonymous (not verified) 67.129.252.2 Nextec 4050 Westmark Drive, Dubuque, Iowa 52002 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-14 Susan Kern skern@kendallhunt.com Dubuque Dubuque Iowa Paul Kern Matthew Johnston Signed (1) The corporation rejects the employers’ liability coverage. Greg Feltes gfeltes@westmarkdevelopment.com Officer Dubuque Dubuque Iowa Dana Feltes Cole Feltes Signed
276 2021-06-17 16:00 Anonymous (not verified) 204.155.61.217 Gentle Bend Inc 1075 120th Street Wellman, IA 52356 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. 2021-06-17 Greg Gent gentagincorporated@gmail.com Wellman Washington Iowa Jeff Spenner Shawn Powell Signed (1) The corporation rejects the employers’ liability coverage. Greg Gent gentagincorporated@gmail.com Owner Wellman Washington Iowa Jeff Spenner Shawn Powell Signed
122 2020-10-05 15:21 Anonymous (not verified) 173.24.190.134 Greg Haldin Construction, Inc. PO Box 387, Sioux Rapids, IA 50585 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. 2020-10-06 Greg Haldin ghconstruction@live.com Sioux Rapids Buena Vista IA Candie Clark Scott Wirtz Signed (1) The corporation rejects the employers’ liability coverage. Greg Haldin ghconstruction@live.com President Sioux Rapids Buena Vista IA Candie Clark Scott Wirtz Signed
864 2024-01-23 14:31 Anonymous (not verified) 94.188.207.230 Firm Foundation Concrete PO Box 164 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. 2024-01-23 Greg Schut firmfoundationbros@gmail.com Sioux Center Sioux Iowa Erica Schut Miguel Perez Signed (1) The corporation rejects the employers’ liability coverage. Greg Schut firmfoundationbros@gmail.com Owner Sioux Center Sioux IA Erica Schut Miguel Perez Signed
484 2022-06-02 08:31 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 Gregory Liddle judy@fullenkampins.com Wever Lee Iowa Chris Fullenkamp judy moeller Signed (1) The corporation rejects the employers’ liability coverage. Gregory Liddle judy@fullenkampins.com President Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed
209 2021-03-19 11:44 Anonymous (not verified) 206.80.128.67 GSW Farms INC 25277 HWY K45 Onawa, IA 51040 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. 2021-03-19 Gregory Willey sgwilley@gmail.com Onawa Monona Iowa Jacob Willey Brad Rock Signed (1) The corporation rejects the employers’ liability coverage. Gregory Willey sgwilley@gmail.com President Onawa Monona Iowa Jacob Willey Brad Rock Signed
608 2023-02-22 16:15 Anonymous (not verified) 94.188.207.225 Unity Global Inc 1779 Shooting Star Ave, Fairfield, IA 52556 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. 2023-01-04 Hagen Rainbow unityglobalinc@protonmail.com Fairfield Jefferson Iowa Peter Defreitas Barbara Rainbow Signed (1) The corporation rejects the employers’ liability coverage. Hagen Rainbow unityglobalinc@protonmail.com President Fairfield Jefferson Iowa Peter Defreitas Barbara Rainbow Signed
745 2023-08-17 11:29 Anonymous (not verified) 94.188.207.226 NIEMEYER WELL AND PUMP INC 2735 GARFIELD AVE, HULL IA 51239 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 HAROLD NIEMEYER handmpump@gmail.com FREEMAN HUTCHINSON SD JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The corporation rejects the employers’ liability coverage. HAROLD NIEMEYER handmpump@gmail.com SELF FREEMAN HUTCHINSON SD JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
853 2024-01-16 13:21 Anonymous (not verified) 94.188.207.230 NeX Level Moving 5634 Deerwood St SW Cedar Rapids, IA 52404 United States 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. 2024-01-16 Hayden Schaefer Wagner 24haywag24@gmail.com Cedar Rapids Linn Iowa Stephanie Allegra Wagner Hayden Schaefer Wagner Signed (1) The corporation rejects the employers’ liability coverage. Hayden Schaefer Wagner 24haywag24@gmail.com Self Cedar Rapids Linn Iowa Hayden Schaefer Wagner Stephanie Allegra Wagner Signed
51 2020-03-30 11:01 Anonymous (not verified) 45.42.5.219 Iowa Roofpros 104 Anderson Street, Maquoketa, IA 52060 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-03-17 Heather Nienke heather@nienkesolar.com Maquoketa Jackson Iowa Derrick Parsons Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. Heather Nienke heather@nienkesolar.com Co-owners Maquoketa Jackson Iowa Derrick Parsons Brenda Lewis Signed
620 2023-03-06 09:26 Anonymous (not verified) 94.188.207.225 Monhec industrial construction llc 616 sw 62 nd st desmoines iowa 50312 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-06 Hector Montoya halexisjr@hotmail.com Desmoines Polk Iowa Adriana rojo Jeremy boeck Signed (1) The corporation rejects the employers’ liability coverage. Hector Montoya halexisjr@hotmail.com Owner Desmoines Polk Iowa Adriana rojo Jeremy boeck Signed
280 2021-06-29 16:51 Anonymous (not verified) 50.83.167.103 King Kleen LLC 421 S. 6th Street, Burlington, IA 52601 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. 2021-06-29 Heidi King Kingbizsol@gmail.com Burlington Des Moines Iowa Ethan King Bob King Signed (1) The corporation rejects the employers’ liability coverage. Heidi King ethan@kingkleen.biz Owner Burlington Des Moines Iowa Ethan King Robert King Signed
21 2019-12-30 11:28 Anonymous (not verified) 207.191.194.182 Bob Stephen Motors Inc 324 W Main St, Manchester IA 52057 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2019-11-05 Paul Roussell twyladetrich@gmail.com MANCHESTER DELAWARE IA Traci Lyons Allie DeVore Signed (1) The corporation rejects the employers’ liability coverage. Heidi Roussell twyladetrich@gmail.com Vice President Manchester DELAWARE IA Traci Lyons Allie DeVore Signed
610 2023-02-23 16:19 Anonymous (not verified) 94.188.207.228 Glorious tile service llc 3905 NE 6th st Ankeny IA 50021 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2023-02-23 Heileselaisi unguec glorioustile6@gmail.com Ankeny United States IOWA Robert duku Abraham deng Signed (2) The corporation declines to reject the employers’ liability coverage. Heileselaisi unguec glorioustile6@gmail.com Owner llc member Ankeny United States Iowa Robert duku Abraham deng Signed
952 2024-04-08 17:25 Anonymous (not verified) 94.188.205.175 Bio-Inspired Design Aeronautics Corp 6843 Still Creek Pass 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. 2024-03-08 Joseph Mitchell aerotech@hush.com Bettendorf Iowa United States Mike Owens Chris DeCock Signed (1) The corporation rejects the employers’ liability coverage. Hollie Mitchell mitchhollie@yahoo.com Vice President Bettendorf Iowa United States Mike Owens Chris DeCock Signed
439 2022-03-29 19:23 Anonymous (not verified) 173.215.72.139 Vinton Enterprises LLC 24704 Isbell Lane, Glenwood, IA 51534 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 Holly Vinton vintonfive@hotmail.com Glenwood Mills Iowa David Pratt Chad MIller Signed (1) The corporation rejects the employers’ liability coverage. Holly Vinton vintonfive@hotmail.com owner Glenwood Mills Iowa David Pratt Chad Miller Signed
264 2021-05-18 22:36 Anonymous (not verified) 174.71.14.68 Town and country Aqua Club 22687 James 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. 2021-05-18 Hope LaShea Diercks townandcountrycb@gmail.com Council bluffs Pottawattamie Iowa John James Diercks Keenan James Diercks Signed (1) The corporation rejects the employers’ liability coverage. Hope LaShea Diercks townandcountrycb@gmail.com Treasurer Council bluffs Pottawattamie Iowa John James Diercks Keenan James Diercks Signed
870 2024-01-26 07:57 Anonymous (not verified) 94.188.207.228 Kodiak Group Security LLC 1978 NW 92nd CT STE 2 Clive, Iowa 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-23 Howard Alton Johnston Jr howard@kodiakgroup.org Stuart Adair IA Joseph Crawford Howard Williams Signed (1) The corporation rejects the employers’ liability coverage. Howard Alton Johnston Jr howard@kodiakgroup.org Owner Stuart Adair Iowa Jospeh Crawford Howard Williams Signed
485 2022-06-02 08:33 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 Hugh Vandgriff judy@fullenkampins.com Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Hugh Vandegriff Judy@fullenkampins.com board member Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed
102 2020-07-19 14:42 Anonymous (not verified) 208.90.8.234 Humboldt County Agricultural Society 311 N 6th Ave P.O. Box 391, Humboldt, IA 50548 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. 2020-07-19 Paul Davis dfs72@yahoo.com Humboldt Humboldt IA Marva Anderson Paul Davis Signed (1) The corporation rejects the employers’ liability coverage. Humboldt County Agricultural Society info@humboldtcountyfair.com Business Manager Humboldt 81 IA Marva Anderson Jeff Halverson Signed
105 2020-07-24 18:21 Anonymous (not verified) 74.115.101.23 Humboldt County Agricultural Society 311 N 6th Ave P.O. Box 391, Humboldt, IA 50548 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. 2020-07-24 Kevin Cordray kwcordray@gmail.com Humboldt Humboldt IA Marva Anderson Jeff Halverson Signed (1) The corporation rejects the employers’ liability coverage. Humboldt County Agricultural Society info@humboldtcountyfair.com Business Manager Humboldt Humboldt IA Marva Anderson Jeff Halverson Signed
344 2021-10-07 15:22 Anonymous (not verified) 73.191.238.89 Kleaveland Brothers, Inc c/o 5724 36th Avenue, Ne. Seattle, WA 98105 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. 2021-10-07 I. Justin Kleaveland justinqt@comcast.net North Muskegon Muskegon MI Amanda A. Finch Enrika L.F. McGahan Signed (1) The corporation rejects the employers’ liability coverage. I. Justin Kleaveland justinqt@comcast.net Vice President North Muskegon Muskegon MI Amanda A. Finch Enrika L.F. McGahan Signed
669 2023-05-15 09:26 Anonymous (not verified) 94.188.207.229 SOUTHWEST IOWA ELECTRIC LLC 800 NW SPRUCE ST,EARLHAM, IA 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. 2023-05-12 ISAAC NORTON NORTON2412@GMAIL.COM EARLHAM DALLAS IOWA GARRETT ROBINSON ADDILIE NORTON Signed (1) The corporation rejects the employers’ liability coverage. ISAAC NORTON NORTON2412@GMAIL.COM PRESIDENT EARLHAM DALLAS IOWA GARRETT ROBINSON ADDILIE NORTON Signed
238 2021-04-16 08:25 Anonymous (not verified) 66.43.227.177 Zern Farm Corp 15109 330th St. Conrad, IA 50621 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-03 Jack Zern nicole.stone@gnbins.com Conrad Grundy Iowa Nicole Stone Jeff Beeghly Signed (1) The corporation rejects the employers’ liability coverage. Jack Zern nicole.stone@gnbins.com President Conrad Grundy Iowa Nicole Stone Jeff Beeghly Signed
752 2023-08-21 14:04 Anonymous (not verified) 94.188.205.177 Johnson Custom Paint and Design, LLC 1414 N 9th street Fort Dodge Iowa 50501 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-21 Joshua Johnson jackiejohnson1251@gmail.com Fort dodge Webster Iowa Jacklyn Johnson Roger Johnson Signed (1) The corporation rejects the employers’ liability coverage. Jacklyn Johnson jackiejohnson1251@gmail.com Wife Fort dodge Webater Iowa Jacklyn Johnson Roger Johnson Signed
201 2021-03-04 10:04 Anonymous (not verified) 104.193.30.26 JDS TRANSFER, INC. 22327 60TH ST, OELWEIN, IA 50662 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-04 AMANDA S. KOESTER STAMP210@HOTMAIL.COM OELWEIN FAYETTE IOWA KACIE DERR LEANNA STAMP Signed (1) The corporation rejects the employers’ liability coverage. JACOB D STAMP STAMP210@HOTMAIL.COM PRESIDENT OELWEIN FAYETTE IOWA KACIE DERR LEANNA STAMP Signed
487 2022-06-02 08:36 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. 2022-05-25 Jacob Denning judy@fullenkampins.com Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Jacob Denning judy@fullenkampins.com Board Member Wever Lee Iowa Chris Fullenkamp Judy Moeller Signed
793 2023-10-18 08:18 Anonymous (not verified) 94.188.205.168 J&M Tire and Repair 31006 hedge 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. 2023-10-18 Jacob Mills Barkley jmtireandrepair@gmail.com sioux city Iowa United States Alex Barkley Victoria Barkley Signed (1) The corporation rejects the employers’ liability coverage. Jacob Mills Barkley jmtireandrepair@gmail.com Owner sioux city Iowa United States Alex Barkley Victoria Barkley Signed
835 2023-12-13 08:41 Anonymous (not verified) 94.188.207.226 J&M Tire and Repair LLC 31006 hedge 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. 2022-12-13 Jacob Mills Barkley jmtireandrepair@gmail.com sioux city Iowa United States Evan Cook Kevin Vothj Signed (1) The corporation rejects the employers’ liability coverage. Jacob Mills Barkley jmtireandrepair@gmail.com Owner sioux city Iowa United States Evan Cook Kevin Voth Signed
837 2023-12-13 08:51 Anonymous (not verified) 94.188.207.228 J&M Tire and Repair LLC 31006 Hedge 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. 2023-12-13 Jacob Mills Barkley jmtireandrepair@gmail.com Sioux city Plymouth Iowa Kevin Voth Evan Cook Signed (1) The corporation rejects the employers’ liability coverage. Jacob Mills Barkley jmtireandrepair@gmail.com Owner Sioux City Plymouth Iowa Kevin Voth Evan Cook Signed
682 2023-06-07 16:10 Anonymous (not verified) 94.188.207.223 Jake's Insulation Inc. 2020 Valley High Dr. Cedar Falls, IA I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-07 Jacob Ryan Smalley jakersmalley@gmail.com Cedar Falls Black Hawk Iowa Emily D Smalley Allison L Smalley Signed (1) The corporation rejects the employers’ liability coverage. Jacob Ryan Smalley jakersmalley@gmail.com President Cedar Falls Black Hawk Iowa Emily Smalley Allison Smalley Signed
282 2021-06-30 12:31 Anonymous (not verified) 204.155.61.217 Stout Roofing Inc 1200 Ash St, Dallas Center, IA 50063 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-06-30 Jacob Stout jacobstout@hailmayday.com Dallas Center Dallas County IA Ashley Kraft Docusign Signed (1) The corporation rejects the employers’ liability coverage. Jacob Stout jacobstout@hailmayday.com Owner Dallas center Dallas IA Ashley Kraft Docusign Signed
981 2024-05-10 15:31 Anonymous (not verified) 94.188.205.168 Jacob Thompson DBA Jake Thompson Trucking 2524 Delta Ave, Bridgewater, IA 50837 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 Jake Thompson jakethompsontrucking@yahoo.com Bridgewater Adair Iowa Daniela Scacchi Jeff Thompson Signed (1) The corporation rejects the employers’ liability coverage. Jake Thompson jakethompsontrucking@yahoo.com Self Bridgerwater Adair IA Daniela Scacchi Jeff Thompson Signed
166 2021-01-21 08:52 Anonymous (not verified) 66.102.212.10 English River Transport, Inc. 2015 Highway 22, 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. 2021-01-13 James A Yoder fisheria@kctc.net Kalona Washington IA Christian Swartzentruber Judy Showalter Signed (1) The corporation rejects the employers’ liability coverage. James A Yoder christian@fisherins.com President Kalona Washington IA Christian Swartzentruber Judy Showalter Signed
419 2022-03-03 14:37 Anonymous (not verified) 68.13.47.145 Trility Group Holdings, Inc 14001 University Ave, Suite 300 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. 2022-03-03 James Brody Deren brody@trility.io Omaha Douglas Nebraska Devin Boyer Kyle Woiwood Signed (1) The corporation rejects the employers’ liability coverage. James Brody Deren brody@trility.io Secretary Omaha Douglas Nebraska Devin Boyer Kyle Woiwood Signed
411 2022-02-23 15:06 Anonymous (not verified) 173.19.163.201 DK Pluming and Excavating 12439 S 60TH AVE W 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 JAMES DONAHOO DKPIPELLC@GMAIL.COM PRAIRIE CITY Jasper IA David Graber Matt Bengston Signed (1) The corporation rejects the employers’ liability coverage. James Donahoo DKPIPELLC@GMAIL.COM Owner PRAIRIE CITY Jasper IA David Graber Matt Bengston Signed
527 2022-08-18 12:44 Anonymous (not verified) 75.146.219.201 James F. Valentine, Inc. 300 Thomas Avenue, Bldg 401, Williamstown, NJ 08094 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. 2022-08-18 James F. Valentine jvalentine@valentineassoc.com Williamstown Gloucester New Jersey Kim Vona Dawn Souder Signed (1) The corporation rejects the employers’ liability coverage. James F Valentine jvalentine@valentineassoc.com Owner Williamstown Gloucester New Jersey Kim Vona Dawn Souder Signed
528 2022-08-22 15:57 Anonymous (not verified) 75.146.219.201 James F. Valentine 300 Thomas Avenue, Bldg 401, Williamstown, NJ 08094 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. 2022-08-22 James F. Valentine jvalentine@valentineassoc.com Williamstown Gloucester New Jersey Kim Vona Dawn Souder Signed (1) The corporation rejects the employers’ liability coverage. James F. Valentine jvalentine@valentineassoc.com Owner Williamstown Gloucester New Jersey Kim Vona Dawn Souder Signed
349 2021-10-22 11:08 Anonymous (not verified) 63.152.48.235 Strong Rock and Gravel LLC 721 S Front St, Lansing, IA 52151 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-04 Ronald Strong stronggravel@gmail.com Llansing Allamakee Iowa James H Bieber Jane Tepesch Signed (1) The corporation rejects the employers’ liability coverage. James H Bieber biebinre@qwestoffice.net Insurance Agent WAUKON Allamakee Iowa James H Bieber Jane Tepesch Signed
623 2023-03-08 13:48 Anonymous (not verified) 94.188.205.174 Jim & Laini's Trucking Inc 11591 Rupp Hollow 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. 2023-03-08 James Harry jltiowa@gmail.com DUBUQUE IA United States Christopher T Clarke Chris Clarke Signed (1) The corporation rejects the employers’ liability coverage. James Harry jltiowa@gmail.com owner DUBUQUE IA United States Christopher T Clarke Chris Clarke Signed
624 2023-03-08 13:50 Anonymous (not verified) 94.188.205.177 Jim & Laini's Trucking Inc 11591 Rupp Hollow 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. 2023-03-08 Elaine Harry jltiowa@gmail.com DUBUQUE Iowa United States Christopher T Clarke Chris Clarke Signed (1) The corporation rejects the employers’ liability coverage. James Harry jltiowa@gmail.com owner DUBUQUE IA United States Christopher T Clarke Chris Clarke Signed
198 2021-03-03 17:14 Anonymous (not verified) 173.29.156.163 Jdw 329 E. 11th st davenport iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-03 James holzer slickninja00@gmail.com Davenport Scott Iowa Alyssa holzer Kory munn Signed (2) The corporation declines to reject the employers’ liability coverage. James holzer slickninja00@gmail.com Myself Davenport Scott Iowa Alyssa holzer Kory munn Signed
731 2023-08-04 09:43 Anonymous (not verified) 94.188.207.229 Hopp's Computers & More 855 S. Page St., Nauvoo, IL 62354 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. 2023-08-04 James Hopp tech@hoppcomputers.com Nauvoo Hancock Illinois Carol McGhghy Ana LeVesque Signed (1) The corporation rejects the employers’ liability coverage. James Hopp tech@hoppcomputers.com Owner Nauvoo Hancock Illinois Carol McGhghy Ana LeVesque Signed
347 2021-10-14 19:28 Anonymous (not verified) 75.162.50.106 Dawn's Daycare 360 NW Walnut Ave Earlham,Iowa 50072 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-10-14 James J Stonehocker j_stonehocker@hotmail.com Earlham Madison iowa Anne Larson Alison Werts Signed (1) The corporation rejects the employers’ liability coverage. James J Stonehocker j_stonehocker@hotmail.com Owner Earlham Madison Iowa Anne Larson Alison Werts Signed
450 2022-04-20 13:42 Anonymous (not verified) 96.85.81.137 D&K Harvesting Inc. P.o Box 1347 LaBelle Fl 33975 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-20 James Larry Marsh Jr larrym3041@aol.com Fort myers Lee Florida Anita Coronado Christy Pequeno Signed (2) The corporation declines to reject the employers’ liability coverage. James Larry Marsh Jr larrym3041@aol.com Owner Fort myers Lee Florida Anita Coronado Christy Puequeno Signed