123 |
2020-10-20 17:35 |
Anonymous (not verified) |
66.172.250.9 |
Ladwig Constrution |
509 Moorehead St. Ida Grove, IA 51445 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-10-20 |
Ross Ladwig |
rossladwig@gmail.com |
Ida Grove |
Ida |
Iowa |
Christine Ladwig |
Kya Ladwig |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Ross Ladwig |
rossladwig@gmail.com |
Owner |
Ida Grove |
Ida |
Iowa |
Christine Ladwig |
Kya Ladwig |
Signed |
958 |
2024-04-17 13:16 |
Anonymous (not verified) |
94.188.207.223 |
1st Choice Builders |
10095 Hickman Ct #2 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-17 |
Scott Todd |
scott.todd85@yahoo.com |
West Des Moines |
Polk |
Iowa |
Danielle Pryor |
Ronnie Lee Todd |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott Todd |
scott.todd85@yahoo.com |
self |
West Des Moines |
Polk |
Iowa |
Danielle Pryor |
Ronnie Lee Todd |
Signed |
645 |
2023-03-31 08:55 |
Anonymous (not verified) |
94.188.205.166 |
3Fitt Life, Inc. |
28345 Highway 52, Bellevue, IA 52031 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-31 |
Ann L Wachtel |
annw@3fitt.com |
Bellevue |
Jackson |
Iowa |
Jeff Laban |
Katie Laban |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ann L Wachtel |
annw@3fitt.com |
President |
Bellevue |
Jackson |
Iowa |
Jeff Laban |
Katie Laban |
Signed |
193 |
2021-03-02 11:32 |
Anonymous (not verified) |
50.83.72.164 |
4 corners drywall |
532 w 15 st, Davenport, iowa 52803 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2021-03-02 |
Phillip hoxsey |
Phillhoxsey81@gmail.com |
Davenport |
Scott |
Iowa |
Donivan hoxsey |
Connor ruge |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Phillip hoxsey |
Phillhoxsey81@gmail.com |
Owner |
Davenport |
Scott |
Iowa |
Donivan hoxsey |
Connor ruge |
Signed |
839 |
2023-12-18 16:12 |
Anonymous (not verified) |
94.188.207.227 |
515 Painting llc |
po box 157 |
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 |
Marvin S Parker JR |
stvpkr@gmail.com |
berwick |
polk |
iowa |
Christopher Eldridge |
Dillon Parker |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Marvin parker |
stvpkr@gmail.com |
owner |
berwick |
Polk |
Iowa |
Christopher Eldridge |
Dillon Parker |
Signed |
410 |
2022-02-20 19:10 |
Anonymous (not verified) |
173.27.233.68 |
A and W marble and tile Inc |
207 Philip St. Des Moines, Iowa 50315 |
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. |
2022-02-20 |
Wayne Yergy |
wyergy@gmail.com |
Des Moines |
Polk |
Iowa |
John Noga |
Angie Carter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Wayne A Yergy |
wyergy@gmail.com |
Vice President |
Des Moines |
IA |
United States |
John Noga |
Angie Carter |
Signed |
133 |
2020-11-15 19:57 |
Anonymous (not verified) |
75.162.166.182 |
A Metro Snow Removal and lawn care llc |
6436 Washington 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. |
2020-11-15 |
Jeff Lamp |
Jeff.lamp79@gmail.com |
Windsor hieghts |
IA |
United States |
Jill Fresh |
Rick Brown |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
A Metro Snow Removal and lawn Care llc |
Jeff.lamp79@gmail.com |
Owner |
Windsor hieghts |
IA |
United States |
jill Fresh |
Rick Brown |
Signed |
279 |
2021-06-23 10:41 |
Anonymous (not verified) |
184.80.177.137 |
AA Breeders |
P.O. Box 470 - Epworth, IA 52045 |
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. |
2021-06-22 |
Justin Curtis |
jheims@english-insurance.com |
Epworth |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
AA Breeders - Justin Curtis |
jheims@english-insurance.com |
self |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
580 |
2022-12-09 11:20 |
Anonymous (not verified) |
74.84.79.78 |
Aaron Alley |
101 Teale St. Davis City, IA 50065 |
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 |
Aaron Alley |
alleyre@hotmail.com |
Davis City |
Decatur |
Iowa |
Michael O'Conner |
Ron Rand |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Aaron Alley |
alleyre@hotmail.com |
owner |
Davis City |
Decatur |
Iowa |
Michael O'Conner |
Ron Rand |
Signed |
539 |
2022-09-22 18:03 |
Anonymous (not verified) |
166.181.87.86 |
Abarrotes La Salud, Inc. |
17 North 1st Street |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2022-09-22 |
Gabriela Vargas Avalos |
mtownlasalud@gmail.com |
Marshalltown |
Marshall |
Iowa |
Antonio Ramirez Sanchez |
Genoveva Alvizu Hernandez |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Gabriela Vargas Avalos |
mtownlasalud@gmail.com |
Vice President |
Marshalltown |
Marshall |
Iowa |
Antonio Ramirez Sanchez |
Genoveva Alvizu Hernandez |
Signed |
593 |
2023-01-30 10:39 |
Anonymous (not verified) |
69.18.9.193 |
ABC Fire Extinguisher Sales & Service, Inc. |
112 Broadway Street Suite 2, West Burlington, IA 52655 |
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. |
2023-01-01 |
Derek Stotlar |
contactabc@abc-fire.com |
Sperry |
Des Moines |
IA |
Kori Stotlar |
Jeff Elliott |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kori Stotlar |
kstotlar@abc-fire.com |
President |
Sperry |
Des Moines |
IA |
Jeff Elliott |
Kim Eland |
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 |
740 |
2023-08-14 10:25 |
Anonymous (not verified) |
94.188.205.167 |
Absolute Mud Jacking Inc |
5038 Brittany Ct Bettendorf Iowa 52722 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-12 |
Paul Pelzer |
pelzer830@gmail.com |
Bettendorf |
IA |
United States |
Brett Lewandowski |
Phil Schaefer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Pelzer |
pelzer830@gmail.com |
Owner |
Bettendorf |
IA |
United States |
Brett Lewandowski |
Phil Schaefer |
Signed |
537 |
2022-09-20 09:01 |
Anonymous (not verified) |
173.20.206.50 |
Accent Painting LLC |
613 Locust ST |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-09-20 |
Anthony Gilbert Gasco |
accentpainting@yahoo.com |
La Porte City |
Blackhawk |
Iowa |
Arthur Rudolf Gasco |
Aurora Jealee Gasco |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Anthony Gilbert Gasco |
accentpainting@yahoo.com |
Owner |
La Porte City |
Blackhawk |
Iowa |
Arthur Rudolf Gasco |
Aurora Jealee Gasco |
Signed |
480 |
2022-05-30 11:37 |
Anonymous (not verified) |
134.215.6.237 |
Access Property Management Corp DBA Wine & Spirits |
510 E Carrington Ln, Appleton, WI 54913 |
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. |
2022-05-30 |
Lisa M Ricklefs |
lisarick19@yahoo.com |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferek |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Thomas Ricklefs |
tjrick@yahoo.com |
President |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferak |
Signed |
481 |
2022-05-30 11:42 |
Anonymous (not verified) |
134.215.6.237 |
Access Property Management Corp DBA Wine & Spirits |
510 E Carrington Ln, Appleton, WI 54913 |
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. |
2022-05-30 |
Thomas J Ricklefs |
tjrick@yahoo.com |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferek |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa M Ricklefs |
lisarick19@yahoo.com |
VP |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferek |
Signed |
75 |
2020-04-29 11:07 |
Anonymous (not verified) |
107.77.206.22 |
ACR Construction, Inc |
7330 NW 21 St. 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. |
2020-04-29 |
Andre Sean Drost |
andre.drost@acr-construction-inc.com |
Ankeny |
Polk |
IA |
Heidi Smith |
Jeff Smith |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Candace Drost |
acrdrost@hotmail.com |
President |
Ankeny |
Polk |
IA |
Heidi Smith |
Jeff Smith |
Signed |
829 |
2023-11-27 08:59 |
Anonymous (not verified) |
94.188.207.224 |
Adam Ruess Masonry |
206.w Elm 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. |
2023-11-27 |
Adam Ruess |
ruess33@gmail.com |
Lone Tree |
IA |
United States |
Adam Ruess |
Adam Ruess |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam Ruess |
ruess33@gmail.com |
Owner |
Lone Tree |
IA |
United States |
Adam Ruess |
Adam Ruess |
Signed |
436 |
2022-03-29 11:07 |
Anonymous (not verified) |
184.80.177.137 |
Adam Sheppard |
22194 260th St - Delhi, 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. |
2022-03-24 |
Adam Sheppard |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam Sheppard |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
642 |
2023-03-30 09:56 |
Anonymous (not verified) |
94.188.205.174 |
Adamantine Spine Moving |
2726 Independence Road Iowa City, Iowa 52240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-30 |
John Clifford Wallace |
cliff.wallace@spinemoving.com |
Des Moines |
Polk |
IA |
Taylor Christian Roth |
Ashley Anne Koch |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ashley Anne Koch |
ashley.koch@spinemoving.com |
HR, Safety and Compliance Manager |
Des Moines |
Polk |
Iowa |
Taylor Christian Roth |
John Clifford Wallace |
Signed |
643 |
2023-03-30 09:58 |
Anonymous (not verified) |
94.188.205.175 |
Adamantine Spine Moving |
2726 Independence Rd., Iowa City, IA 52240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-30 |
Emily Wallace |
emily.wallace@spinemoving.com |
Des Moines |
Polk |
Iowa |
John Wallace |
Ashley Koch |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ashley Koch |
ashley.koch@spinemoving.com |
Human Resources Manager |
West Des Moines |
Polk |
Iowa |
John Wallace |
Taylor Roth |
Signed |
969 |
2024-05-02 16:15 |
Anonymous (not verified) |
94.188.205.175 |
Adamantine Spine Moving |
2726 Independence Rd Iowa City, IA 52240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-02 |
John Clifford Wallace |
cliff.wallace@spinemoving.com |
Des Moines |
Polk |
Iowa |
John Thomas Wallace |
Amanda Root Wallace |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bill Hoke |
bill.hoke@spinemoving.com |
HR |
Des Moines |
Polk |
County |
Sarah Mannix |
Erika Banks |
Signed |
970 |
2024-05-02 16:15 |
Anonymous (not verified) |
94.188.205.167 |
Adamantine Spine Moving |
2726 Independence Rd., Iowa City, IA 52240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-02 |
Emily Wallace |
emily.wallace@spinemoving.com |
Des Moines |
Polk |
Iowa |
Margaret Walter |
Dan Walter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William Hoke |
bill.hoke@spinemoving.com |
Owner |
Iowa City |
Johnson |
Iowa |
Sarah Mannix |
Erika Banks |
Signed |
728 |
2023-08-03 12:28 |
Anonymous (not verified) |
94.188.205.166 |
Advanced Plumbing LLC |
2538 Carbide Ln, Keokuk, IA 52632 |
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. |
2023-08-03 |
James O'Shea |
advancedplumbing1@yahoo.com |
Keokuk |
Iowa |
United States |
Rebecca O'Shea |
Tate O'Shea |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James O'Shea |
advancedplumbing1@yahoo.com |
Partner |
Keokuk |
Iowa |
United States |
Rebecca O'Shea |
Tate O'Shea |
Signed |
47 |
2020-03-10 15:16 |
Anonymous (not verified) |
65.126.161.162 |
Advantage Customer Remodeling LLC |
3236 W 17th Street 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. |
2020-03-10 |
Tamethia Mitchell |
None@none.com |
Davenport |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tamethia Mitchell |
None@none.com |
Owner |
Davenport |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
263 |
2021-05-06 15:18 |
Anonymous (not verified) |
174.243.113.232 |
Agronomic Solutions |
908 E Dubuque St Quasqueton IA 52326 |
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. |
2021-05-06 |
Brandy Hodges |
mapping@agsolutionsinc.net |
Coon Rapids |
IA |
United States |
Jacki Sloss |
Don Sloss |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Friday Insurance |
doug.miller@fridayinsurance.net |
agent |
Osceola |
Clarke |
IA |
Jacki Sloss |
Don Sloss |
Signed |
214 |
2021-03-28 12:59 |
Anonymous (not verified) |
172.86.34.18 |
Agronomic Solutions, INC |
1614 Fir Avenue Coon Rapids, IA 50058 |
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. |
2021-03-28 |
Nickolas Lee Steffens |
nsteffens@agsolutionsinc.net |
Quasqueton |
Buchanan |
Iowa |
Julia Sperfslage |
Andrew Sperfslage |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nickolas Lee Steffens |
nsteffens@agsolutionsinc.net |
Owner/ Vice President |
Quasqueton |
Buchanan |
Iowa |
Andrew Sperfslage |
Julia Sperfslage |
Signed |
208 |
2021-03-16 16:19 |
Anonymous (not verified) |
204.155.61.217 |
AGSPIRE INC |
1310 Kathryn Ct Buffalo, MN 55313 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-02 |
Kent Kiebelkorn |
kent@hailmayday.com |
Buffalo |
Wright County |
Minnesota |
Docusign |
Docusign |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
unknown |
akraft@millerhartwig.com |
Unknown |
unknown |
unknown |
unknown |
unknown |
unknown |
Signed |
210 |
2021-03-22 15:20 |
Anonymous (not verified) |
204.155.61.217 |
Agspire Inc |
1310 Kathryn Ct Buffalo, MN 55313 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-05 |
Kent Fiebelkorn |
kent@hailmayday.com |
Buffalo |
Wright County |
Minnesota |
DocuSign |
Ashley Kraft |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kent Fiebelkorn |
kent@hailmayday.com |
Owner |
Buffalo |
Wright County |
Minnesota |
DocuSign |
Ashley Kraft |
Signed |
854 |
2024-01-16 14:59 |
Anonymous (not verified) |
94.188.207.226 |
AJS Sanitation LLC |
504 Locust, St, PO Box 144, Minburn, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-16 |
Jason Mash |
jmash79@yahoo.com |
Minburn |
Dallas |
Iowa |
Don Richardson |
Abbey Luellen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jason Mash |
jmash79@yahoo.com |
President |
Minburn |
Dallas |
Iowa |
Don Richardson |
Abbey Luellen |
Signed |
155 |
2021-01-06 15:50 |
Anonymous (not verified) |
216.81.153.249 |
Al's Inc DWB CW&T |
1509 Richland Drive, Storm Lake, IA 5058 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-29 |
Robert Bauer |
NONE@GMAIL.COM |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Bauer |
NONE@GMAIL.COM |
Owner |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
156 |
2021-01-06 15:52 |
Anonymous (not verified) |
216.81.153.249 |
Al's Inc DWB CW&T |
1509 Richland Drive, Storm Lake, IA 5058 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-29 |
Jon Bauer |
NONE@GMAIL.COM |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jon Bauer |
None@gmail.com |
Owner |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
157 |
2021-01-06 15:53 |
Anonymous (not verified) |
216.81.153.249 |
Al's Inc DWB CW&T |
1509 Richland Drive, Storm Lake, IA 5058 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-29 |
April Coleman |
NONE@GMAIL.COM |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
April Coleman |
None@gmail.com |
Owner |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
158 |
2021-01-06 15:54 |
Anonymous (not verified) |
216.81.153.249 |
Al's Inc DWB CW&T |
1509 Richland Drive, Storm Lake, IA 5058 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-29 |
Julie Deucker |
NONE@GMAIL.COM |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Julie Duecker |
None@gmail.com |
Owner |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
777 |
2023-10-02 08:50 |
Anonymous (not verified) |
94.188.205.176 |
Alexandria Munro |
7020 Forest Drive, Johnston, IA 50131 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-02 |
Alexandria Munro |
armunro17@gmail.com |
Johnston |
Polk |
Iowa |
John Goodhue |
Miranda Cyr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Alexandria Munro |
armunro17@gmail.com |
Owner |
Johnston |
Polk |
Iowa |
John Goodhue |
Miranda Cyr |
Signed |
178 |
2021-02-13 00:06 |
Anonymous (not verified) |
172.58.87.80 |
All Cut Lawncare and Landscaping LLC |
3506 Glover Ave. Des Moines Iowa 50315 |
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. |
2021-02-12 |
Michael David Money |
moneymichael811@gmail.com |
Des Moines |
Polk |
Iowa |
Diana Jennings |
Deanna L Phagan |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael David Miney |
mineymichael811@gmail.com |
Owner and President |
Des Moines |
Polk |
Iowa |
Diana Jennings |
Deanna L Phagan |
Signed |
140 |
2020-11-25 12:43 |
Anonymous (not verified) |
63.152.43.202 |
All Heart Staffing, Inc. |
4403 1ST AVE. SE, SUITE 310, 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. |
2020-11-01 |
Joel Katcher |
Joel@AllHeartStaffing.com |
CEDAR RAPIDS |
IA |
United States |
Andy Becker |
Kathryn Brown |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joel Katcher |
Joel@AllHeartStaffing.com |
President |
CEDAR RAPIDS |
IA |
United States |
Andy Becker |
Kathryn Brown |
Signed |
956 |
2024-04-12 14:23 |
Anonymous (not verified) |
205.221.255.62 |
All things power wash ATP LLC |
2730 Lafayette, Sioux City, IA 51104 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-12 |
Anthony Rowe |
allthingspowerwash4usiouxcity@gmail.com |
Sioux City |
Woodbury |
Iowa |
Franzis Rios |
Tamara Bawi |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Anthony Rowe |
allthingspowerwash4usiouxcity@gmail.com |
Owner |
Sioux City |
Woodbury |
Iowa |
Franzis Rios |
Tamara Bawi |
Signed |
562 |
2022-11-04 10:32 |
Anonymous (not verified) |
98.159.123.124 |
Alli-Center |
555 Cameron Way Unit 2 North Liberty Iowa 52317 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-11-04 |
Bonnie Seely |
bseely4@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Jonah C Seely |
Hannah Seely |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bonnie Seely |
bseely4@gmail.com |
Owner/Self |
Cedar Rapids |
Linn |
Iowa |
Jonah Seely |
Hannah Seely |
Signed |
932 |
2024-03-22 21:55 |
Anonymous (not verified) |
94.188.205.175 |
Alternative Sport Enterprises |
101 Highway 1 West Iowa City IA 52246 |
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. |
2024-03-22 |
Nick John Carroll |
hatchetjacksiowa@gmail.com |
CORALVILLE |
Johnson County |
Iowa |
Payton Kahl |
Trey Kahl |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Michael Pearson |
hatchetjacksiowa@gmail.com |
Owner |
Savage |
Scott County |
Minnesota |
Payton Kahl |
Trey Kahl |
Signed |
933 |
2024-03-22 21:55 |
Anonymous (not verified) |
94.188.205.176 |
Alternative Sport Enterprises |
101 Highway 1 West Iowa City IA 52246 |
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. |
2024-03-22 |
James Michael Pearson |
hatchetjacksiowa@gmail.com |
Savage |
Scott County |
Minnesota |
Payton Kahl |
Trey Kahl |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nick John Carroll |
hatchetjacksiowa@gmail.com |
Owner |
CORALVILLE |
Johnson County |
Iowa |
Payton Kahl |
Trey Kahl |
Signed |
652 |
2023-04-17 16:23 |
Anonymous (not verified) |
94.188.205.177 |
alternative sport enterprises llc |
506 6th st 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. |
2023-04-17 |
nick carroll |
nick.carroll@mchsi.com |
Coralville |
IA |
United States |
Kaylyn Olson |
Jake Braman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
nick carroll |
nick.carroll@mchsi.com |
owner |
Coralville |
IA |
United States |
Kaylyn Olson |
Jake Braman |
Signed |
653 |
2023-04-17 16:37 |
Anonymous (not verified) |
94.188.205.166 |
alternative sport enterprises llc |
506 6th 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. |
2023-04-17 |
James Pearson |
jimpearson444@yahoo.com |
Savage |
scott |
MN |
Kaylyn Olson |
Jake Braman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
nick carroll |
nick.carroll@mchsi.com |
Owner |
Coralville |
IA |
United States |
Kaylyn Olson |
Jake Braman |
Signed |
200 |
2021-03-03 17:33 |
Anonymous (not verified) |
172.58.84.30 |
Amee Ann Pepperson |
1536 1/2 W Locust |
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 |
Amee Ann Pepperson |
amee0818@yahoo.com |
Davenport |
Scott |
Iowa |
Philip Gerald Hoxsey |
Michael Wayne Underdahl |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Amee A Pepperson |
amee0818@yahoo.com |
Self |
Davenport |
Scott |
Iowa |
Michael Wayne Underdahl |
Philip Gerald Hoxsey |
Signed |
117 |
2020-09-11 11:54 |
Anonymous (not verified) |
162.218.1.22 |
american business resource corporation |
4600 American Parkway Suite #301 Madison, WI 53718 |
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 |
Michelle Szabrowicz |
mszabrowicz@abrjobs.com |
Madison |
Dane |
Wisconsin |
Patricia Haggerty |
Britney Mollet |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michelle Szabrowicz |
mszabrowicz@abrjobs.com |
CFO |
Madison |
Dane |
Wisconsin |
Patricia Haggerty |
Britney Mollet |
Signed |
646 |
2023-03-31 13:58 |
Anonymous (not verified) |
94.188.205.168 |
American Residential Services Inc |
1683 Elizabeth Dr Marion IA 52302 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-31 |
Robert Rettmann |
americanres@yahoo.com |
Apple Valley |
Dakota |
MN |
Nancy Rettmann |
William Dilts |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Rettmann |
americanres@yahoo.com |
President |
Apple Valley |
Dakota |
MN |
Nancy Rettmann |
William Dilts |
Signed |
845 |
2024-01-02 09:03 |
Anonymous (not verified) |
94.188.205.169 |
American Tree Service LLC |
416 S Kiel Street, Holstein, IA 51025 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-02 |
Austin Thevenot |
americantreeservice03@gmail.com |
Holstein |
Ida |
Iowa |
Jared Brashears |
Katie Gunkelman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Austin Thevenot |
americantreeservice03@gmail.com |
Owner |
Holstein |
Ida |
Iowa |
Jared Brashears |
Katie Gunkelman |
Signed |
832 |
2023-12-07 09:57 |
Anonymous (not verified) |
94.188.207.226 |
Andrew Garberson |
400 SW 42nd Street, 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. |
2023-12-07 |
Andrew Garberson |
andrew.garberson@gmail.com |
Des Moines |
Polk |
IA |
Jeanette Harris |
Emily Feriz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andrew Garberson |
andrew.garberson@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Jeanette Harris |
Emily Feriz |
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 |
941 |
2024-04-03 10:26 |
Anonymous (not verified) |
94.188.207.223 |
Andrew Renna |
407 19th st spirit lake Iowa 51369 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-03 |
Andrew John Renna |
drewrenna86@gmail.com |
Spirit lake |
Dickinson |
Iowa |
Brianna Lene |
Nicholas Omang |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andrew Renna |
drewrenna86@gmail.com |
Owner |
Spirit lake |
Dickinson |
Iowa |
Brianna Lene |
Nicholas Omang |
Signed |