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 |
486 |
2022-06-02 08:34 |
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 |
Craig Pieper |
judy@fullenkampins.com |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Craig Pieper |
Judy@fullenkampins.com |
Vice President |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
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 |
649 |
2023-04-07 11:56 |
Anonymous (not verified) |
94.188.207.223 |
Wilcox Property Management Inc |
300 N. 3rd St, Carlisle, IA 50047 |
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. |
2023-04-07 |
William Wilcox |
bill@advancedasi.com |
Carlisle |
Polk |
IA |
Gary J Meyers |
James R Simmons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William Wilcox |
bill@advancedasi.com |
Owner |
Carlisle |
Polk |
IA |
Gary J Meyers |
James R Simmons |
Signed |
940 |
2024-04-03 07:49 |
Anonymous (not verified) |
94.188.205.167 |
Wildride Trucking |
3261 old river rd sw. Cedar Rapids 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. |
2024-04-03 |
David mckee |
wildride1969@gmail.com |
Cedar Rapids |
Lynn |
Ia |
Valerie mckee |
Dillon Williams |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dave mckee |
wildride1969@gmail.com |
Owner |
Cedar Rapids |
Lynn |
Ia |
Valerie mckee |
Dillon Williams |
Signed |
678 |
2023-06-06 10:28 |
Anonymous (not verified) |
94.188.205.177 |
William Terrance Harshbarger Jr. |
27225 115th Avenue, Donahue IA 52746 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-06 |
William Terrance Harshbarger Jr. |
harzyhd1@hotmail.com |
Donahue |
Scott |
Iowa |
Margaret Tucker |
Cheryl Piersall |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William Terrance Harshbarger Jr. |
harzyhd1@hotmail.com |
self |
Donahue |
Scott |
Iowa |
Margaret Tucker |
Cheryl Piersall |
Signed |
679 |
2023-06-06 10:36 |
Anonymous (not verified) |
94.188.205.174 |
William Terrance Harshbarger Jr. |
27225 115th Avenue, Donahue IA 52746 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-06 |
William Terrance Harshbarger Jr. |
harzyhd1@hotmail.com |
Donahue |
Scott |
Iowa |
Margaret Tucker |
Cheryl Piersall |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William Terrance Harshbarger Jr. |
harzyhd1@hotmail.com |
self |
Donahue |
Scott |
Iowa |
Margaret Tucker |
Cheryl Piersall |
Signed |
361 |
2021-11-15 18:08 |
Anonymous (not verified) |
199.66.15.123 |
Wills Work |
302 N Kenwood Blvd |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-11-15 |
Timothy Williams Robinson |
williamswork18@gmail.com |
Indianola |
Warren |
Iowa |
Andrew Gilbert Barber |
Sarah Anne Robinson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Timothy Will Robinson |
williamswork18@gmail.com |
CEO |
Indianola |
Warren |
Iowa |
Andrew Gilbert Barber |
Sarah Anne Robinson |
Signed |
700 |
2023-06-22 11:03 |
Anonymous (not verified) |
94.188.207.229 |
WIT Systems Corporation |
313 Brentwood Dr NE, Cedar Rapids, IA 52402 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-22 |
DOUGLAS K WILLIAMS |
dkwilliams@witsystems.com |
Cedar Rapids IA |
Linn |
CT |
Patrick Gavin |
Kaley Gavin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
DOUGLAS K WILLIAMS |
dkwilliams@witsystems.com |
President |
CEDAR RAPIDS |
IA |
United States |
Patrick Gavin |
Kaley Gavin |
Signed |
258 |
2021-05-06 10:57 |
Anonymous (not verified) |
76.79.44.61 |
Woltemath Farm Inc |
3096 300th Ave, Hamburg, Ia 51640 |
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 |
Robert Woltemath |
rwoltem@gmail.com |
HAMBURG |
IA |
United States |
Lisa Reinier |
Sheryl Owen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sandra Lynn Graybill |
sndygra@gmail.com |
Officer/ Owner |
Council Bluffs |
Pottawattamie |
IA |
Lisa Reinier |
Sheryl Owen |
Signed |
259 |
2021-05-06 11:00 |
Anonymous (not verified) |
76.79.44.61 |
Woltemath Farm Inc |
3096 300th Ave, Hamburg, Ia 51640 |
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 |
Sandra Lynn Graybill |
sndygra@gmail.com |
Council Bluffs |
Pottawattamie |
United States |
Lisa Reinier |
Sheryl Owen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Woltemath |
rwoltem@gmail.com |
Officer/ Owner |
Hamburg |
Fremont |
IA |
Lisa Reinier |
Sheryl Owen |
Signed |
260 |
2021-05-06 11:12 |
Anonymous (not verified) |
76.79.44.61 |
Woltemath Farm Inc |
3096 300th 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. |
2021-05-06 |
Robert Allen Woltemath |
rwoltem@gmail.com |
Hamburg |
Fremont |
IA |
Lisa Reinier |
Sheryl Owen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sandra Lynn Graybill |
sndygra@gmail.com |
Officer/Owner |
Council Bluffs |
Pottawattamie |
IA |
Lisa Reinier |
Sheryl Owen |
Signed |
261 |
2021-05-06 11:31 |
Anonymous (not verified) |
76.79.44.61 |
WOLTEMATH FARM INC |
3096 300TH AVE, Hamburg, IA 51640 |
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 |
Robert Allen Woltemath |
rwoltem@gmail.com |
Hamburg |
Fremont |
IOWA |
Lisa Reinier |
Sheryl Own |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sandra Lynn Graybill |
sndygra@gmail.com |
Owner/ Officer |
Council Bluffs |
Pottawattamie |
IA |
Lisa Reinier |
Sheryl Owen |
Signed |
749 |
2023-08-20 16:36 |
Anonymous (not verified) |
94.188.207.225 |
Wonderfully Made LLC |
2003 Downing Ave Waterloo IA 50701 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-20 |
Víctor Manuel Martinez Jr. |
martinezvic54@gmail.com |
Waterloo |
Black Hawk |
IA |
Trey Patterson |
Lauren Shaff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Alexis Lise Martinez |
victorandleximartinez@gmail.com |
Owner |
Waterloo |
Black Hawk |
IA |
Trey Patterson |
Lauren Shaff |
Signed |
750 |
2023-08-20 16:41 |
Anonymous (not verified) |
94.188.207.229 |
Wonderfully Made LLC |
2003 Downing Ave Waterloo IA 50701 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-20 |
Alexis Lise Martinez |
victorandleximartinez@gmail.com |
Waterloo |
Black Hawk |
IA |
Trey Patterson |
Lauren Shaff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Alexis Lise Martinez |
victorandleximartinez@gmail.com |
Owner |
Waterloo |
Black Hawk |
IA |
Trey Patterson |
Lauren Shaff |
Signed |
307 |
2021-08-13 15:21 |
Anonymous (not verified) |
65.154.100.34 |
World of Reptiles Inc dba Snakes Alive |
3901 NW Seasons Ct 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. |
2021-08-09 |
Ron Goodman |
ron_goo@msn.com |
Ankeny |
Polk |
IA |
Megan Matlock |
Tom Weidner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ron Goodman |
ron_goo@msn.com |
Owner |
Ankeny |
Polk |
IA |
Megan Matlock |
Tom Weidner |
Signed |
308 |
2021-08-13 15:23 |
Anonymous (not verified) |
65.154.100.34 |
World of Reptiles Inc dba Snakes Alive |
3901 NW Seasons Ct 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. |
2021-08-09 |
Tom Weidner |
mmatlock@thedanaco.com |
Des Moines |
Polk |
IA |
Megan Matlock |
Ron Goodman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tom Weidner |
mmatlock@thedanaco.com |
Owner |
Des Moines |
Polk |
IA |
Megan Matlock |
Ron Goodman |
Signed |
311 |
2021-08-16 12:25 |
Anonymous (not verified) |
65.154.100.34 |
World of Reptiles Inc dba Snakes Alive |
3901 NW Seasons Ct 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. |
2021-08-09 |
Ron Goodman |
mmatlock@thedanaco.com |
Ankeny |
Polk |
IA |
Megan Matlock |
Tom Weidner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ron Goodman |
mmatlock@thedanaco.com |
Owner |
Ankeny |
Polk |
IA |
Megan Matlock |
Tom Weidner |
Signed |
699 |
2023-06-21 14:04 |
Anonymous (not verified) |
94.188.205.166 |
WRS Inc |
5225 NE 17th St. Des Moines, 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. |
2023-06-21 |
Kevin A Alderman |
alderman@wrsia.com |
Urbandale |
Iowa |
United States |
John Kaldenberg |
Ronda Perry |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kevin Alderman |
alderman@wrsia.com |
President / Owner |
Urbandale |
Iowa |
United States |
John Kaldenberg |
Ronda Perry |
Signed |
570 |
2022-11-16 10:35 |
Anonymous (not verified) |
50.81.253.108 |
XU's Golden Dragon |
508 Chestnut St., Atlantic, IA 50022 |
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. |
2022-11-16 |
Xu Long |
125529647@QQ.COM |
Atlantic |
Cass |
IA |
Richard Crall |
Shannon Crall |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Richard Crall |
richard@partnersins.com |
Insurance Agent |
Atlantic |
Cass |
United States |
Shannon Crall |
Richard Crall |
Signed |
571 |
2022-11-16 10:40 |
Anonymous (not verified) |
50.81.253.108 |
XU's Golden Dragon |
508 Chestnut St., Atlantic, IA 50022 |
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. |
2022-11-16 |
Tingjie Huang |
125529647@QQ.COM |
Atlantic |
Cass |
IA |
Richard Crall |
Shannon Crall |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Richard Crall |
richard@partnersins.com |
Insurance Agent |
Atlantic |
Cass |
United States |
Shannon Crall |
Richard Crall |
Signed |
598 |
2023-02-10 09:38 |
Anonymous (not verified) |
94.188.207.225 |
Y & M Cleaning Services Inc. |
4380 SE 15th Ct |
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. |
2023-02-10 |
Martine Martinez |
martinmtzmartinez@gmail.com |
Des Moines |
Polk |
Iowa |
Suzanne E Collier |
Andy Boyd |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Suzanne E Collier |
scollie1@amfam.com |
Non Related |
Altoona |
Polk |
IA |
Andy Boyd |
Martin Martinez |
Signed |
795 |
2023-10-18 14:29 |
Anonymous (not verified) |
94.188.205.169 |
Yarn Tree Designs Inc |
117 Alexander Ave, Ames, IA 50010 |
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 |
Sarah Beth Johnson |
Beth@yarntree.com |
Ames |
Story |
Iowa |
Megan Chriswisser |
Erica Lenig |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Larry R Johnson |
larry@yarntree.com |
VP |
Ames |
Story |
Iowa |
Megan Chriswisser |
Erica Lenig |
Signed |
796 |
2023-10-18 14:34 |
Anonymous (not verified) |
94.188.205.177 |
Yarn Tree Designs Inc |
117 Alexander Ave, Ames, IA 50010 |
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 |
Larry R Johnson |
larry@yarntree.com |
Ames |
Story |
Iowa |
Megan Chriswisser |
Erica Lenig |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Larry R Johnson |
larry@yarntree.com |
VP |
Ames |
Story |
Iowa |
Megan Chriswisser |
Erica Lenig |
Signed |
318 |
2021-08-23 11:00 |
Anonymous (not verified) |
216.51.164.69 |
Z Homes and Realty Inc |
1324 3rd Ave SE Sioux Center IA 51250 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-19 |
Beverly Zwart |
mbzwrt@mtcnet.net |
Sioux Center |
Sioux |
IA |
Lisa Dykstra |
Blake Kruger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Beverly Zwart |
mbzwrt@mtcnet.net |
Owner |
Sioux Center |
Sioux |
IA |
Lisa Dykstra |
Blake Kruger |
Signed |
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 |
239 |
2021-04-16 08:28 |
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 |
Danice Zern |
nicole.stone@gnbins.com |
Conrad |
Grundy |
Iowa |
Nicole Stone |
Jeff Beeghly |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Danice Zern |
nicole.stone@gnbins.com |
Treasurer |
Conrad |
Grundy |
Iowa |
Nicole Stone |
Jeff Beeghly |
Signed |
240 |
2021-04-16 08:30 |
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 |
Cloris Zern |
nicole.stone@gnbins.com |
Conrad |
Grundy |
Iowa |
Nicole Stone |
Jeff Beeghly |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cloris Zern |
nicole.stone@gnbins.com |
Secretary |
Conrad |
Grundy |
Iowa |
Nicole Stone |
Jeff Beeghly |
Signed |