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Rejection of Workers' Compensation or Employers' Liability Coverage

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# Submitted User IP address Name of Corporation: Address of Corporation Home Office: Statement 1 Agreement: Statement 2 Agreement: Statement 3 Agreement: Statement Agreement: Check Either Alternative (1) or (2): Date: Full Name of Individual: Email: City of Residence: County of Residence: State of Residence: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Agreement: Alternative Selection: Full Name of Authorized Agent: Email of Authorized Agent: Relationship to Corporation of Authorized Agent: City of Residence: County of Residence: State: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Indication:
713 2023-07-25 12:26 Anonymous (not verified) 94.188.205.174 HT&T Drywall 479 old lincoln hwy Mechanicsville Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-25 Tracy Spray tspray9@hotmail.com Mechanicsville Cedar Iowa Dillon Williams Leighton Raplinger Signed (1) The corporation rejects the employers’ liability coverage. Tracy Spray tspray9@hotmail.com Owner Mechanicsville Cedar Iowa Dillon Williams Leighton Raplinger Signed
718 2023-07-27 08:43 Anonymous (not verified) 94.188.207.225 HT&T Drywall 479 Old Lincoln Hwy I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-27 Tracy Spray tspray9@hotmail.com Mechanicsville Cedar Iowa Dillon Williams Leighton Raplinger Signed (1) The corporation rejects the employers’ liability coverage. Tracy Spray tspray9@hotmail.com Owner Mechanicsville Cedar Iowa Dillon Williams Leighton Raplinger Signed
406 2022-02-15 17:30 Anonymous (not verified) 173.18.126.91 Huff Construction 1309 Business 30 sw Mount Vernon 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. 2022-02-15 Jason Huff jason@huff-construction.com Mount Vernon Linn Iowa Katie Huff Rick Deneve Signed (1) The corporation rejects the employers’ liability coverage. Jason Huff jason@huff-construction.com Owner Mount Vernon Linn Iowa Katie Huff Rick Deneve Signed
407 2022-02-16 15:44 Anonymous (not verified) 173.18.126.91 Huff Construction LLC 1309 Business 30 Sw I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-16 Jason Huff jason@huff-construction.com Mount Vernon Linn Iowa Katie Huff Rick Deneve Signed (1) The corporation rejects the employers’ liability coverage. Jason Huff jason@huff-construction.com Owner Mount Vernon Linn Iowa Katie Huff Rick Deneve Signed
96 2020-07-03 16:51 Anonymous (not verified) 208.90.8.234 Humboldt Co. Ag Society 311 6th Ave. N Humboldt 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. 2020-07-03 Jeffrey D. Halverson roadgear54@yahoo.com Hardy Humboldt Iowa Marva Anderson Paul Davis Signed (1) The corporation rejects the employers’ liability coverage. Jeffrey Halverson roadgear54@yahoo.com Vice President Hardy Humboldt Iowa Marva Anderson Paul Davis Signed
141 2020-12-02 09:34 Anonymous (not verified) 208.90.15.53 Humboldt Community Daycare, Inc. DBA Kiddie Cats Childcare and Learning Center P.O. Box 93 Dakota City, Ia 50529 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-02 Travis Goedken travisg@cityofhumboldt.org Humboldt Humboldt Iowa Ross Sleiter Lance Dewinter Signed (1) The corporation rejects the employers’ liability coverage. Travis Goedken travisg@cityofhumboldt.org President Humboldt Humboldt Iowa Ross Sleiter Lance Dewinter Signed
142 2020-12-02 09:39 Anonymous (not verified) 208.90.15.53 Humboldt Community Daycare, Inc. DBA Kiddie Cats Childcare and Learning Center P.O. Box 93 Dakota City, Ia 50529 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-02 Angelique Berry dcity@goldfieldaccess.net Algona Kossuth Iowa Ross Sleiter Scott Curran Signed (1) The corporation rejects the employers’ liability coverage. Angelique Berry dcity@goldfieldaccess.net Secretary/Treasurer Algona Kossuth Iowa Ross Sleiter Scott Curran Signed
143 2020-12-02 09:43 Anonymous (not verified) 208.90.15.53 Humboldt Community Daycare, Inc. DBA Kiddie Cats Childcare and Learning Center P.O. Box 93 Dakota City, Ia 50529 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-02 Rob Dickey robd@fsbwc.com Gilmore City Humboldt Iowa Ross Sleiter Scott Curran Signed (1) The corporation rejects the employers’ liability coverage. Rob Dickey robd@fwbwc.com Vice President Gilmore City Humboldt Iowa Ross Sleiter Scott Curran Signed
100 2020-07-14 19:08 Anonymous (not verified) 208.90.8.234 Humboldt County Agricultural 311 N 6th Ave, P.O. Box 391, Humboldt, IA 50548 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-07-18 Jeff Haselhuhn gjhaselhuhn@gmail.com Humboldt Humboldt IA Marva Anderson Jeff Halverson Signed (1) The corporation rejects the employers’ liability coverage. Marva Anderson info@humboldtcountyfair.com Business Manager Humboldt 81 81 Marva Anderson Jeff Halverson Signed
102 2020-07-19 14:42 Anonymous (not verified) 208.90.8.234 Humboldt County Agricultural Society 311 N 6th Ave P.O. Box 391, Humboldt, IA 50548 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-07-19 Paul Davis dfs72@yahoo.com Humboldt Humboldt IA Marva Anderson Paul Davis Signed (1) The corporation rejects the employers’ liability coverage. Humboldt County Agricultural Society info@humboldtcountyfair.com Business Manager Humboldt 81 IA Marva Anderson Jeff Halverson Signed
105 2020-07-24 18:21 Anonymous (not verified) 74.115.101.23 Humboldt County Agricultural Society 311 N 6th Ave P.O. Box 391, Humboldt, IA 50548 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-07-24 Kevin Cordray kwcordray@gmail.com Humboldt Humboldt IA Marva Anderson Jeff Halverson Signed (1) The corporation rejects the employers’ liability coverage. Humboldt County Agricultural Society info@humboldtcountyfair.com Business Manager Humboldt Humboldt IA Marva Anderson Jeff Halverson Signed
172 2021-01-26 19:02 Anonymous (not verified) 173.17.8.56 Hutch's Parking Lot Sweeping 5235 JENNIFER DR I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-26 Bill HUTCHINSON btnwhutch@aol.com PLEASANT HILL Iowa United States TRACY HUTCHINSON WHITNIE HUTCHINSON Signed (1) The corporation rejects the employers’ liability coverage. Bill HUTCHINSON btnwhutch@aol.com Self PLEASANT HILL Iowa United States TRACY HUTCHINSON WHITNIE HUTCHINSON Signed
337 2021-09-16 21:28 Anonymous (not verified) 173.17.8.56 Hutch's Parking Lot Sweeping Inc. 5235 Jennifer Dr I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-16 Bill E Hutchinson btnwhutch@aol.com Pleasant Hill Iowa Iowa Tracy Hutchinson Nic Hutchinson Signed (1) The corporation rejects the employers’ liability coverage. Bill E Hutchinson btnwhutch@aol.com Same Pleasant Hill Iowa Iowa Tracy Hutchinson Nic Hutchinson Signed
647 2023-04-04 11:51 Anonymous (not verified) 94.188.207.225 Ibarra's Construction LLC 4125 56th Street Des Moines IA 50310 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-04-04 Serafin Orendain Rivera serafinorivera334@gmail.com Des Moines Polk Iowa Saul Orendain Maricela Pillado Signed (2) The corporation declines to reject the employers’ liability coverage. Matt Thompson mthompson@urscompliance.com Agent Minneapolis Hennepin County MN Maricela Pillado Saul Orendain Signed
648 2023-04-04 14:43 Anonymous (not verified) 94.188.207.224 IBARRAS CONSTRUCTION LLC 4125 56th St Des Moines IA 50310 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-04-04 SERAFIN ORENDAIN RIVERA ld.hispanicservicesllc@gmail.com Moines Polk County IA Lizeth Mora Felipe Pardo Signed (1) The corporation rejects the employers’ liability coverage. SERAFIN ORENDAIN RIVERA ld.hispanicservicesllc@gmail.com Member Moines Polk County IA Lizeth Mora Felipe Pardo Signed
461 2022-05-02 11:08 Anonymous (not verified) 192.119.212.86 Iceberg Enterprises LLC 101 E. 1st street Arthur IA 51431 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. 2022-05-02 Jesse Bergman jk_montana@yahoo.com arthur Iowa United States Maren Smith Darren Smith Signed (1) The corporation rejects the employers’ liability coverage. Katherine Bergman jk_montana@yahoo.com Owner Arthur IOWA United States Susan Bergman Jesse Bergman Signed
579 2022-12-07 14:37 Anonymous (not verified) 96.31.1.206 IGL RENTAL LLC PO BOX 317 ARNOLDS PARK IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-10-25 CHAD JONES STAYBOJI@GMAIL.COM ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The corporation rejects the employers’ liability coverage. CHAD JONES STAYBOJI@GMAIL.COM MEMBER ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
316 2021-08-23 10:15 Anonymous (not verified) 70.119.220.61 Iles Funeral Homes Inc. 6337 Hickman Rd, Des Moines, IA 50322 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-07-07 C Michael Iles mike.iles@ilesscares.com Heath Rockwall Texas Susan Lancaster Kathryn Mann Signed (1) The corporation rejects the employers’ liability coverage. C Michael Iles mike.iles@ilescares.com Vice President Heath Rockwall Texas Susan Lancaster Kathryn Mann Signed
317 2021-08-23 10:19 Anonymous (not verified) 70.119.220.61 Iles Funeral Homes Inc. 6337 Hickman Rd, Des Moines, IA 50322 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-07-07 Mark Iles mark.iles@ilescares.com Clive Polk Iowa Lori Crabb Paul Marshall Signed (1) The corporation rejects the employers’ liability coverage. C Michael Iles mike.iles@ilescares.com Vice President Heath Rockwall Texas Susan Lancaster Kathryn Mann Signed
462 2022-05-02 16:01 Anonymous (not verified) 71.39.227.238 IN SEASON LAWN CARE LLC 32841 HOMESTEAD DR, GRANGER, IA 50109 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. 2022-05-02 JOSEPH CRAIG COVER inseason98@gmail.com Granger Dallas Iowa Abbey Luellen Steve Phillips Signed (1) The corporation rejects the employers’ liability coverage. Joseph Craig Cover inseason98@gmail.com Owner Granger Dallas Iowa Abbey Luellen Steve Phillips Signed
463 2022-05-02 16:02 Anonymous (not verified) 71.39.227.238 IN SEASON LAWN CARE LLC 32841 HOMESTEAD DR, GRANGER, IA 50109 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. 2022-05-02 CHEYENNE COVER inseason98@gmail.com Granger Dallas Iowa Abbey Luellen Steve Phillips Signed (1) The corporation rejects the employers’ liability coverage. CHEYENNE Cover inseason98@gmail.com Owner Granger Dallas Iowa Abbey Luellen Steve Phillips Signed
738 2023-08-11 08:47 Anonymous (not verified) 94.188.207.223 Infrastructure Engineering, Inc. 1451 NE 69TH PL, Ste 42 Ankeny, IA 50021 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-11 Joel Peiffer peifferj@ieidsm.com Ankeny Polk Iowa Bret Larkins Heather Cornwell Signed (1) The corporation rejects the employers’ liability coverage. Joel Peiffer peifferj@ieidsm.com Owner ANKENY Iowa Iowa Bret Larkins Heather Cornwell Signed
670 2023-05-18 12:21 Anonymous (not verified) 94.188.205.175 innovations General contractors 1134 20th ave East Moline IL 61244 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. 2022-05-18 Juan Carlos innovationsGENC@gmail.com East Moline Rock Island Illinois Jacinto Perez Lopez Pionaolo Davalos Signed (1) The corporation rejects the employers’ liability coverage. juan Carlos Soto Deanda InnovationsGENC@gmail.com owner East moline Rock Island illinois jacinto Perez Lopez Pianolo Davalos Signed
942 2024-04-03 12:06 Anonymous (not verified) 94.188.205.174 Invisible Fence of NCI, Inc 408 5th St, Ste 100 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. 2024-04-04 Lisa Busch Timm centraliowa@invisiblefence.com Madrid Iowa United States Paul Timm Kari Rigby Signed (1) The corporation rejects the employers’ liability coverage. Lisa Busch Timm centraliowa@invisiblefence.com Self Madrid IA United States Paul Timm Kari Rigby Signed
943 2024-04-03 12:07 Anonymous (not verified) 94.188.205.166 Invisible Fence of NCI, Inc 408 5th St, Ste 100 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. 2024-03-04 Paul Andy Timm ifbcentraliowa@yahoo.com Madrid IA Iowa Lisa Timm Kari Rigby Signed (1) The corporation rejects the employers’ liability coverage. Lisa Busch Timm centraliowa@invisiblefence.com Spouse Madrid IA United States Lisa Timm Kari Rigby Signed
207 2021-03-16 08:34 Anonymous (not verified) 63.152.54.231 Iowa Express Delivery Service Inc. 4021 Old Ferry Road 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. 2021-03-16 Karen Stearns iowaexpressdelivery@gmail.com Palo Linn United States Jeremiah Morris Christina Stearns Signed (1) The corporation rejects the employers’ liability coverage. Karen Stearns iowaexpressdelivery@gmail.com Self Palo Linn United States Jeremiah Morris Christina Stearns Signed
202 2021-03-08 10:43 Anonymous (not verified) 151.147.196.21 Iowa Gold Distributing, Inc. 600 Iehl Street, Central City, IA 52214 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-02-10 Rebeccah Walters igdenv@aol.com Central City Linn Iowa William Walters Jennifer Leinen Signed (1) The corporation rejects the employers’ liability coverage. Rebeccah Walters igdenv@aol.com Secretary Central City Linn Iowa William Walters Jennifer Leinen Signed
203 2021-03-08 10:43 Anonymous (not verified) 151.147.196.21 Iowa Gold Distributing, Inc. 600 Iehl Street, Central City, IA 52214 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-02-10 William R. Walters igdenv@aol.com Central City Linn Iowa Jennifer Leinen Robert L. Hammerberg Signed (1) The corporation rejects the employers’ liability coverage. William R. Walters igdenv@aol.com President Central City Linn Iowa Jennifer Leinen Robert L. Hammerberg Signed
204 2021-03-08 10:43 Anonymous (not verified) 151.147.196.21 Iowa Gold Distributing, Inc. 600 Iehl Street, Central City, IA 52214 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2021-02-10 Brad Coates igdenv@aol.com Central City Linn Iowa William Walters Jennifer Leinen Signed (2) The corporation declines to reject the employers’ liability coverage. Brad Coates igdenv@aol.com Director Central City Linn Iowa William Walters Jennifer Leinen Signed
51 2020-03-30 11:01 Anonymous (not verified) 45.42.5.219 Iowa Roofpros 104 Anderson Street, Maquoketa, IA 52060 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-03-17 Heather Nienke heather@nienkesolar.com Maquoketa Jackson Iowa Derrick Parsons Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. Heather Nienke heather@nienkesolar.com Co-owners Maquoketa Jackson Iowa Derrick Parsons Brenda Lewis Signed
52 2020-03-30 11:04 Anonymous (not verified) 45.42.5.219 Iowa Roofpros 104 Anderson Street, Maquoketa, IA 52060 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-03-17 Jamison Nienke iowaroofguru@gmail.com Maquoketa Jackson Iowa Derrick Parsons Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. Jamison Nienke iowaroofguru@gmail.com Co-owners Maquoketa Jackson Iowa Derrick Parsons Brenda Lewis Signed
916 2024-03-09 12:47 Anonymous (not verified) 94.188.205.174 Iowa Turf Management 3218 castle dr sw, Cedar Rapids IA 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-09 Larrion Eason Iowaturfmanagement@gmail.com cedar rapids linn Iowa Shayla Jameson Shyann Jameson Signed (1) The corporation rejects the employers’ liability coverage. Larrion Eason Iowaturfmanagement@gmail.com self cedar rapids linn Iowa Shayla Jameson Shyann Jameson Signed
128 2020-10-29 07:51 Anonymous (not verified) 74.84.91.178 J & J Drywall LLC 1277 Elm 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. (1) I reject the employers’ liability coverage. 2020-10-27 Jeff Frick frickdbq@gmailc.com Dubuque Dubuque IA Brenda Lewis Gabe Drewelow Signed (1) The corporation rejects the employers’ liability coverage. Jeff Frick frickdbq@gmailc.com president Dubuque Dubuque Iowa Brenda Lewis Gabe Drewelow Signed
433 2022-03-27 15:30 Anonymous (not verified) 208.126.206.146 J B Engraving 206 4th street East Newhall , Iowa 52315 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. 2022-03-27 John Lauterwasser engravingjb@gmail.com Newhall Benton Iowa Lisa Jane Meeks Brandon Lauterwasser Signed (1) The corporation rejects the employers’ liability coverage. LC Anderson lbandins@southslope.net N/A Newhall Benton Iowa Lisa Jane Meeks Brandon Lauterwasser Signed
434 2022-03-27 15:30 Anonymous (not verified) 208.126.206.146 J B Engraving 206 4th street East Newhall , Iowa 52315 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. 2022-03-27 John Lauterwasser engravingjb@gmail.com Newhall Benton Iowa Lisa Jane Meeks Brandon Lauterwasser Signed (1) The corporation rejects the employers’ liability coverage. LC Anderson lbandins@southslope.net N/A Newhall Benton Iowa Lisa Jane Meeks Brandon Lauterwasser Signed
80 2020-05-11 12:29 Anonymous (not verified) 173.191.207.202 J&D Furniture-Land Corp 144 1st Ave East - Dyersville, IA 52040 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-05-07 Scott Hittenmiller dparsons@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Joyce Heims jheims@english-insurance.com agent-English Insurance Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
950 2024-04-08 07:16 Anonymous (not verified) 94.188.207.223 J&J Exteriors 32670 190th st granger Iowa 50109 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. 2024-04-08 Joshua w klein jjexteriorsofiowa@gmail.com Granger Dallas Iowa Leah klein Ethan faughn Signed (1) The corporation rejects the employers’ liability coverage. Joshua klein jjexteriorsofiowa@gmail.com Member Granger Dallas Iowa Leah klein Ethan Faughn Signed
793 2023-10-18 08:18 Anonymous (not verified) 94.188.205.168 J&M Tire and Repair 31006 hedge ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-18 Jacob Mills Barkley jmtireandrepair@gmail.com sioux city Iowa United States Alex Barkley Victoria Barkley Signed (1) The corporation rejects the employers’ liability coverage. Jacob Mills Barkley jmtireandrepair@gmail.com Owner sioux city Iowa United States Alex Barkley Victoria Barkley Signed
794 2023-10-18 08:21 Anonymous (not verified) 94.188.205.177 J&M Tire and Repair 31006 hedge ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-18 Macklin Paul Barkley flyingtank92@yahoo.com merrill Iowa United States Brandon Norris Alex Barkley Signed (1) The corporation rejects the employers’ liability coverage. Macklin Paul Barkley jmtireandrepair@gmail.com Owner sioux city Iowa United States Brandon Norris Alex Barkley Signed
835 2023-12-13 08:41 Anonymous (not verified) 94.188.207.226 J&M Tire and Repair LLC 31006 hedge ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-12-13 Jacob Mills Barkley jmtireandrepair@gmail.com sioux city Iowa United States Evan Cook Kevin Vothj Signed (1) The corporation rejects the employers’ liability coverage. Jacob Mills Barkley jmtireandrepair@gmail.com Owner sioux city Iowa United States Evan Cook Kevin Voth Signed
836 2023-12-13 08:46 Anonymous (not verified) 94.188.207.227 J&M Tire and Repair LLC 31006 hedge ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-13 Macklin Paul Barkley barkley_mack@yahoo.com Merrill Plymouth Iowa Evan Cook Kevin Voth Signed (1) The corporation rejects the employers’ liability coverage. Macklin Barkley jmtireandrepair@gmail.com Owner Merrill Plymouth Iowa Kevin Voth Evan Cook Signed
837 2023-12-13 08:51 Anonymous (not verified) 94.188.207.228 J&M Tire and Repair LLC 31006 Hedge Ave. I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-13 Jacob Mills Barkley jmtireandrepair@gmail.com Sioux city Plymouth Iowa Kevin Voth Evan Cook Signed (1) The corporation rejects the employers’ liability coverage. Jacob Mills Barkley jmtireandrepair@gmail.com Owner Sioux City Plymouth Iowa Kevin Voth Evan Cook Signed
277 2021-06-17 21:34 Anonymous (not verified) 97.125.98.166 J. Bos Holdings 10925 NE 23rd Ave Mitchellville, IA 50169 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-06-17 Jeff Bos jeffbos1967@gmail.com Mitchellville Iowa United States Angela Bos Amy Bos Signed (1) The corporation rejects the employers’ liability coverage. Jeff Bos jeffbos1967@gmail.com officer Mitchellville Iowa United States Angela Bos Amy Bos Signed
252 2021-05-04 13:47 Anonymous (not verified) 159.242.43.24 J. Fox Distributing, Inc 3801 Pierce Street, 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. 2021-05-04 Joseph Fox huskerjoe12@gmail.com Sioux City Woodbury IA Jenny McIntyre Alex Meier Signed (1) The corporation rejects the employers’ liability coverage. Joseph Fox huskerjoe12@gmail.com President Sioux City Woodbury IA Jenny McIntyre Alex Meier Signed
757 2023-08-28 12:11 Anonymous (not verified) 94.188.207.230 J.R. Stelzer Co 5850 Russell Dr. Lincoln, NE 68507 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. 2023-08-28 Mike Stelzer mike@jrstelzer.com Lincoln NE United States Bill Stelzer Jim Stelzer Signed (1) The corporation rejects the employers’ liability coverage. Mike Stelzer mike@jrstelzer.com President Lincoln Lancaster NE Bill Stelzer Jim Stelzer Signed
756 2023-08-28 09:10 Anonymous (not verified) 94.188.205.177 J.R. Stelzer Co. 5850 Russell Dr Ste 1, Lincoln, NE 68507 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-01 William James Stelzer bill@jrstelzer.com Lincoln Nebraska United States Michael G Stelzer Marcia Brouillette Signed (1) The corporation rejects the employers’ liability coverage. William James Stelzer bill@jrstelzer.com Officer Lincoln Lancaster NE Michael G. Stelzer Marcia Brouillette Signed
103 2020-07-23 09:23 Anonymous (not verified) 184.80.177.137 Jacob Reiff 15738 N Cascade Rd - Peosta, IA 52068 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. 2020-07-23 Jacob Reiff jheims@engish-insurance.com Peosta, Dubuque Iowa Joyce Heims Derrick Parsons Signed (2) The corporation declines to reject the employers’ liability coverage. Joyce Heims jheims@english-insurance.com owner Peosta Dubuque Iowa Joyce Heims Derrick Parsons Signed
981 2024-05-10 15:31 Anonymous (not verified) 94.188.205.168 Jacob Thompson DBA Jake Thompson Trucking 2524 Delta Ave, Bridgewater, IA 50837 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-10 Jake Thompson jakethompsontrucking@yahoo.com Bridgewater Adair Iowa Daniela Scacchi Jeff Thompson Signed (1) The corporation rejects the employers’ liability coverage. Jake Thompson jakethompsontrucking@yahoo.com Self Bridgerwater Adair IA Daniela Scacchi Jeff Thompson Signed
682 2023-06-07 16:10 Anonymous (not verified) 94.188.207.223 Jake's Insulation Inc. 2020 Valley High Dr. Cedar Falls, IA I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-07 Jacob Ryan Smalley jakersmalley@gmail.com Cedar Falls Black Hawk Iowa Emily D Smalley Allison L Smalley Signed (1) The corporation rejects the employers’ liability coverage. Jacob Ryan Smalley jakersmalley@gmail.com President Cedar Falls Black Hawk Iowa Emily Smalley Allison Smalley Signed
528 2022-08-22 15:57 Anonymous (not verified) 75.146.219.201 James F. Valentine 300 Thomas Avenue, Bldg 401, Williamstown, NJ 08094 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-08-22 James F. Valentine jvalentine@valentineassoc.com Williamstown Gloucester New Jersey Kim Vona Dawn Souder Signed (1) The corporation rejects the employers’ liability coverage. James F. Valentine jvalentine@valentineassoc.com Owner Williamstown Gloucester New Jersey Kim Vona Dawn Souder Signed