564 |
2022-11-12 13:05 |
Anonymous (not verified) |
152.117.104.212 |
ArborSharp Tree Care LLC |
125 South Russell 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. |
2022-11-12 |
Jonathan Michael Ostermann |
arborsharptc@gmail.com |
Ames |
IA |
IA |
Ben Wyatt |
Marc McClanahan |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jonathan Ostermann |
arborsharptc@gmail.com |
owner |
Ames |
story |
IA |
Ben Wyatt |
Marc McClanahan |
Signed |
689 |
2023-06-19 07:31 |
Anonymous (not verified) |
94.188.207.228 |
Nenger Argueta |
1317 5th Avenue Des Moines, Iowa 50314 |
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. |
2023-06-19 |
Nenger Argueta |
arguetanenger30@gmail.com |
Des Moines |
Polk |
Iowa |
Gelbar Argueta |
Grace Argueta |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nenger Argueta |
arguetanenger30@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Gelbar Argueta |
Grace Argueta |
Signed |
777 |
2023-10-02 08:50 |
Anonymous (not verified) |
94.188.205.176 |
Alexandria Munro |
7020 Forest Drive, Johnston, IA 50131 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-02 |
Alexandria Munro |
armunro17@gmail.com |
Johnston |
Polk |
Iowa |
John Goodhue |
Miranda Cyr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Alexandria Munro |
armunro17@gmail.com |
Owner |
Johnston |
Polk |
Iowa |
John Goodhue |
Miranda Cyr |
Signed |
642 |
2023-03-30 09:56 |
Anonymous (not verified) |
94.188.205.174 |
Adamantine Spine Moving |
2726 Independence Road Iowa City, Iowa 52240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-30 |
John Clifford Wallace |
cliff.wallace@spinemoving.com |
Des Moines |
Polk |
IA |
Taylor Christian Roth |
Ashley Anne Koch |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ashley Anne Koch |
ashley.koch@spinemoving.com |
HR, Safety and Compliance Manager |
Des Moines |
Polk |
Iowa |
Taylor Christian Roth |
John Clifford Wallace |
Signed |
643 |
2023-03-30 09:58 |
Anonymous (not verified) |
94.188.205.175 |
Adamantine Spine Moving |
2726 Independence Rd., Iowa City, IA 52240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-30 |
Emily Wallace |
emily.wallace@spinemoving.com |
Des Moines |
Polk |
Iowa |
John Wallace |
Ashley Koch |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ashley Koch |
ashley.koch@spinemoving.com |
Human Resources Manager |
West Des Moines |
Polk |
Iowa |
John Wallace |
Taylor Roth |
Signed |
350 |
2021-10-25 08:22 |
Anonymous (not verified) |
208.95.64.3 |
Ron Sexton Construction Inc, |
1184 Vine Ave, Riverside IA 52327 |
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. |
2021-09-27 |
Ronald R Sexton |
ashmac@iowatelecom.net |
Riverside |
Washington |
IA |
Greg Martin |
Michele McMichael |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ronald R Sexton |
ashmac@iowatelecom.net |
President |
Riverside |
Washington |
IA |
Greg Martin |
Michele McMichael |
Signed |
351 |
2021-10-25 08:24 |
Anonymous (not verified) |
208.95.64.3 |
Ron Sexton Construction Inc, |
1184 Vine Ave, Riverside IA 52327 |
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. |
2021-09-27 |
Theresa A Sexton |
ashmac@iowatelecom.net |
Riverside |
Washington |
IA |
Greg Martin |
Michele McMichael |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Theresa A Sexton |
ashmac@iowatelecom.net |
VP, Secretary, Treasurer |
Riverside |
Washington |
IA |
Greg Martin |
Michele McMichael |
Signed |
904 |
2024-02-28 06:52 |
Anonymous (not verified) |
94.188.205.167 |
Monarca General Builders LLC. |
551 Martin Rd Waterloo 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. |
2023-12-28 |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
President |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
905 |
2024-02-28 11:47 |
Anonymous (not verified) |
94.188.207.228 |
Monarca General Builders LLC |
551 Martin Rd Waterloo Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-01 |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
Presidente |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
353 |
2021-11-04 11:41 |
Anonymous (not verified) |
108.58.173.242 |
ASTL Moving And Storage Inc |
9530 FM 2920 #227 Tomball TX 77375 |
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. |
2021-11-04 |
Peter Allen III |
astlmoving@yahoo.com |
Tomball |
Harris |
TX |
Peggi Makofka |
Yoel Taran |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Peter Allen III |
astlmoving@yahoo.com |
owner |
Tomball |
Harris |
TX |
Peggi Makofka |
Yoel Taran |
Signed |
734 |
2023-08-09 10:33 |
Anonymous (not verified) |
94.188.207.227 |
Atcher Service LLC |
145 Fremont Street, Hartford, IA 50118 |
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. |
2023-08-08 |
Mandalena K Love |
dlovem2002@gmail.com |
Hartford |
Warren |
Iowa |
Dan Love |
Michael Love |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel J Love |
atcherservicetowing@gmail.com |
owner |
Hartford |
Warren |
Iowa |
Dan Love |
Michael Love |
Signed |
374 |
2021-12-17 08:19 |
Anonymous (not verified) |
69.63.16.2 |
AT Construction Inc. |
5 Westview Acres NE, Iowa City IA 52240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-12-17 |
Tomas Acas |
atconstruction@hotmail.com |
Iowa City |
Johnson |
Iowa |
Steve Fishman |
Dyan Kriener |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tomas Acas |
atconstruction@hotmail.com |
President |
Iowa City |
Johnson |
Iowa |
Steve Fishman |
Dyan Kriener |
Signed |
786 |
2023-10-16 07:27 |
Anonymous (not verified) |
94.188.207.230 |
Aurora Aesthetics and Functional Medicine LLC |
713 1st Ave NW |
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. |
2023-10-04 |
Meagan Mclaughlin |
meagan.vitae@gmail.com |
Mount Vernon |
IA |
United States |
Michael Friess |
Stephanie Friess |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Friess |
Aurorafunctionalmed@gmail.com |
business manager |
Mt Vernon |
IA |
United States |
Stephanie Friess |
Meagan Friess |
Signed |
787 |
2023-10-16 07:30 |
Anonymous (not verified) |
94.188.207.223 |
Aurora Aesthetics and Functional Medicine LLC |
713 1st Ave NW |
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. |
2023-10-04 |
Meagan Mclaughlin |
Aurorafunctionalmed@gmail.com |
Mount Vernon |
IA |
United States |
Stephanie Friess |
Michael Friess |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Friess |
Aurorafunctionalmed@gmail.com |
business manager |
Mount Vernon |
Iowa |
United States |
Meagan Mclaughlin |
Stephanie Friess |
Signed |
789 |
2023-10-16 07:38 |
Anonymous (not verified) |
94.188.205.177 |
Aurora Aesthetics and Functional Medicine LLC |
713 1st Ave NW |
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. |
2023-10-04 |
Michael Friess |
Aurorafunctionalmed@gmail.com |
Mount Vernon |
IA |
United States |
Meagan Mclaughlin |
Stephanie Friess |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Stephanie Friess |
Aurorafunctionalmed@gmail.com |
Owner |
Mount Vernon |
Iowa |
United States |
Michael Friess |
Meagan Mclaughlin |
Signed |
526 |
2022-08-17 11:16 |
Anonymous (not verified) |
173.27.233.86 |
Bradens Roofing and Construction Llc |
2450 Hart Avenue |
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. |
2022-08-17 |
Arsenio Vargas Velazquez |
avargas409@gmail.com |
Des Moines |
polk |
Iowa |
Julissa Dionicio |
Jennifer Dionicio |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Arsenio Vargas Velazquez |
avargas409@gmail.com |
owner |
Des Moines |
Polk |
Iowa |
Julissa Dionicio |
Jennifer Dionicio |
Signed |
626 |
2023-03-16 11:18 |
Anonymous (not verified) |
94.188.207.224 |
Raymond Carpenter |
1655 230th St Tipton IA 52772 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-16 |
Raymond Carpenter |
badseedmudraching@gmail.com |
Tipton |
Cedar |
Iowa |
Mitzi Hoeger |
Roger Gibbs |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Raymond Carpenter |
badseedmudracing@gmail.com |
Self |
Tipton |
Cedar |
IA |
Roger Gibbs |
Mitzi Hoeger |
Signed |
960 |
2024-04-22 18:25 |
Anonymous (not verified) |
94.188.205.174 |
Balvanz Electric LLC |
1517 Greenfield 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. |
2024-04-22 |
Brenton Balvanz |
balvanzelectric@gmail.com |
Marshalltown |
Marshall |
Iowa |
Christin Branon |
Justin Branon |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brenton |
Balvanzelectric@gmail.com |
Owner/President |
Marshalltown |
Marshall |
Iowa |
Christin Branon |
Justin Branon |
Signed |
577 |
2022-12-02 12:31 |
Anonymous (not verified) |
74.84.79.78 |
Juan A. Martinez-Salazar |
7085 Bloomfield Rd. Des Moines, IA 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-02 |
Juan A. Martinez Salazar |
bananas94@icloud.com |
Des Moines |
Polk |
IA |
Racio Rodriguez |
Manuel Gonzalez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Juan A. Martinez- Salazar |
bananas94@icloud.com |
President |
Des Moines |
Polk |
IA |
Racio Rodriguez |
Manuel Gonzales |
Signed |
656 |
2023-04-19 10:46 |
Anonymous (not verified) |
94.188.205.174 |
Brad Anthony Logging LLC |
307 Commercial St, Strawberry Point IA 52076 |
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. |
2023-04-18 |
Brad Anthony |
banthony6487@gmail.com |
Strawberry Point |
Clayton |
Iowa |
Roger Gibbs |
Mitzi Hoeger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Anthony |
banthony6487@gmail.com |
Self |
Strawberry Point |
Clayton |
Iowa |
Mitzi Hoeger |
Roger Gibbs |
Signed |
312 |
2021-08-18 22:29 |
Anonymous (not verified) |
166.181.81.19 |
Basset Express Inc. |
1572 Underwood 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. |
2021-08-18 |
Jay R Chelf |
bassetexpress@yahoo.com |
Muscatine |
Muscatine |
IA |
Bill Petersen |
Jody L Young |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Patricia Ann Chelf |
bassetexpress@gmail.com |
President |
Muscatine |
Muscatine |
Iowa |
Bill Petersen |
Jody L Young |
Signed |
567 |
2022-11-14 18:21 |
Anonymous (not verified) |
166.181.83.71 |
Beasts Bussiness |
1305 N 6th St Apt. 6 Indianola, IA 50125 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-11-14 |
Jonathan Brice Robinson |
Beastsbeekeeping@gmail.com |
Indianola |
Warren |
Iowa |
Timothy Williams Robinson |
Josiah Grant Robinson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jonathan Brice Robinson |
Beastsbeekeeping@gmail.com |
Owner |
Indianola |
Warren |
Iowa |
Timothy Williams Robinson |
Josiah Grant Robinson |
Signed |
245 |
2021-04-22 10:54 |
Anonymous (not verified) |
172.83.18.1 |
Skyway Inc |
7030 27th Way, Clear Lake, IA 50428 |
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. |
2021-04-22 |
Brad Thompson |
becky@fgains.com |
Clear Lake |
Cerro Gordo |
Iowa |
Debbie Otto |
Paxton Farmer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Thompson |
becky@fgains.com |
Owner |
Clear Lake |
Cerro Gordo |
Iowa |
Debbie Otto |
Paxton Farmer |
Signed |
246 |
2021-04-22 10:56 |
Anonymous (not verified) |
172.83.18.1 |
Skyway Inc |
7030 27th Way, Clear Lake, IA 50428 |
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. |
2021-04-22 |
Mary Thompson |
becky@fgains.com |
Clear Lake |
Cerro Gordo |
Iowa |
Debbie Otto |
Paxton Farmer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Thompson |
becky@fgains.com |
Owner |
Clear Lake |
Cerro Gordo |
Iowa |
Debbie Otto |
Paxton Farmer |
Signed |
770 |
2023-09-14 16:23 |
Anonymous (not verified) |
94.188.205.167 |
Volt Electric Inc |
24 Thompson dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-09-14 |
Lucas Beschta |
voltelectriciowa@gmail.com |
Palo |
IA |
United States |
Sage Stulz |
Kolt Stulz-obrien |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Full Name BRIAN C. EDDY |
BEddy@robertseddy.com |
Lawyer for the company |
Independace |
buchanan |
IA |
sage stulz |
Kolt stulz-obrien |
Signed |
449 |
2022-04-19 21:09 |
Anonymous (not verified) |
172.86.44.178 |
Holtkamp Transportation LLC |
2282 Windmill Way, West Point, IA 52656 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-04-19 |
Les Holtkamp |
les@holtkamplogistics.com |
West Point |
Lee |
Iowa |
Ben Hogan |
Tina Holtkamp |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Ben Hogan |
ben@truserveins.com |
Insurance Agent |
Readlyn |
Bremer |
Iowa |
Jaci Hogan |
Nicole Barnes |
Signed |
146 |
2020-12-22 08:48 |
Anonymous (not verified) |
207.155.115.120 |
Kafer Lawn Care |
206 frentress dr Farley, IA 52046 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-22 |
Benjamin Terry Hayes |
benhayes1800@gmail.com |
Epworth |
Dubuque |
IA |
Adam Kafer |
Jeffery Sisler |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Benjamin Terry Hayes |
benhayes1800@gmail.com |
Owner |
Epworth |
Dubuque |
IA |
Adam Kafer |
Jeffery Sisler |
Signed |
181 |
2021-02-18 08:49 |
Anonymous (not verified) |
173.18.193.51 |
Freeman Family Farms Inc |
3125 Glasgow Rd Fairfield Iowa 52556 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-08 |
Phyllis Freeman |
jill@fullenkampins.com |
Fairfield |
Jefferson |
Iowa |
Jill A Garmoe |
Judy K Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Phyllis Freeman |
bfree4020@gmail.com |
Secretary |
Fairfield |
Jefferson |
Iowa |
Jill A Garmoe |
Judy K Moeller |
Signed |
349 |
2021-10-22 11:08 |
Anonymous (not verified) |
63.152.48.235 |
Strong Rock and Gravel LLC |
721 S Front St, Lansing, IA 52151 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-04 |
Ronald Strong |
stronggravel@gmail.com |
Llansing |
Allamakee |
Iowa |
James H Bieber |
Jane Tepesch |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James H Bieber |
biebinre@qwestoffice.net |
Insurance Agent |
WAUKON |
Allamakee |
Iowa |
James H Bieber |
Jane Tepesch |
Signed |
969 |
2024-05-02 16:15 |
Anonymous (not verified) |
94.188.205.175 |
Adamantine Spine Moving |
2726 Independence Rd Iowa City, IA 52240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-02 |
John Clifford Wallace |
cliff.wallace@spinemoving.com |
Des Moines |
Polk |
Iowa |
John Thomas Wallace |
Amanda Root Wallace |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bill Hoke |
bill.hoke@spinemoving.com |
HR |
Des Moines |
Polk |
County |
Sarah Mannix |
Erika Banks |
Signed |
970 |
2024-05-02 16:15 |
Anonymous (not verified) |
94.188.205.167 |
Adamantine Spine Moving |
2726 Independence Rd., Iowa City, IA 52240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-02 |
Emily Wallace |
emily.wallace@spinemoving.com |
Des Moines |
Polk |
Iowa |
Margaret Walter |
Dan Walter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William Hoke |
bill.hoke@spinemoving.com |
Owner |
Iowa City |
Johnson |
Iowa |
Sarah Mannix |
Erika Banks |
Signed |
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 |
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 |
375 |
2021-12-23 12:23 |
Anonymous (not verified) |
66.230.245.47 |
W. R. Elliot & Associates, Ltd. |
3306 Brook Hollow Dr, Asbury, IA 52002 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-12-23 |
William R. Elliot |
bill@wreassoc.com |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L. Spalla |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William R. Elliot |
bill@wreassoc.com |
President |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L Spalla |
Signed |
376 |
2021-12-29 14:40 |
Anonymous (not verified) |
66.230.245.47 |
W. R. Elliot & Associates, Ltd. |
3306 Brook Hollow Dr, Asbury, IA 52002 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-12-29 |
Karen R. Elliot |
karen@handiwerks.com |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L Spalla |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William R. Elliot |
bill@wreassoc.com |
President |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L Spalla |
Signed |
913 |
2024-03-07 07:46 |
Anonymous (not verified) |
94.188.207.229 |
Fair Trade Acoustical Ceiling Services |
3837 5th ave Des Moines, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-07 |
Mathew Bingaman |
Bingaman.matthew1@gmail.com |
Des Moines |
Polk |
Iowa |
Jamie Rose |
Dmitri Mejia |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mathew Bingaman |
Bingaman.matthew1@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Jamie Rose |
Dmitri Mejia |
Signed |
518 |
2022-07-21 10:58 |
Anonymous (not verified) |
75.162.31.164 |
Bengard Roofing LLC |
1927 Wethersfield Dr, Norwalk, IA 50211 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-07-21 |
Brandon Bengard |
bj@bengardroofing.com |
Norwalk |
Warren |
IA |
Rebecca Bengard |
Juhl Bengard |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brandon Bengard |
bj@bengardroofing.com |
Owner |
Norwalk |
Warren |
IA |
Becky Bengard |
Juhl Bengard |
Signed |
906 |
2024-02-29 16:16 |
Anonymous (not verified) |
94.188.205.168 |
Bradley K. Gaul Handyman Services |
740 Cedar Valley Road, Tipton, IA 52772 |
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. |
2024-02-29 |
Bradley Keith Gaul |
bjgjal33@aol.com |
Tipton |
Cedar |
Iowa |
Jill Lynette Gaul |
Logan Benjamin Gaul |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradley Keith Gaul |
bjgjal33@aol.com |
Self |
Tipton |
Cedar |
Iowa |
Jill Lynette Gaul |
Logan Benjamin Gaul |
Signed |
86 |
2020-06-03 17:56 |
Anonymous (not verified) |
75.162.69.231 |
Blackford Foundations Inc |
501 SW Franklin Dr, Ankeny, IA 50023 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-05-01 |
Denny Lee Blackford |
blackfordfoundations@gmail.com |
Ankeny |
Polk |
Iowa |
Saree Luce |
Ricky Eatwell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Denny Lee Blackford |
blackfordfoundations@gmail.com |
Secretary |
Ankeny |
Polk |
Iowa |
Saree Luce |
Ricky Eatwell |
Signed |
804 |
2023-10-31 13:04 |
Anonymous (not verified) |
94.188.207.226 |
NeX Level Restoration LLC |
314 8th ST NW, Cedar Rapids, IA 52405 |
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. |
2023-10-31 |
Bobby Caldwell SR |
blc5000@msn.com |
Cedar Rapids |
Linn |
IA |
Adam Feldmann |
Tarin Tanner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bobby Caldwell |
blc5000@msn.com |
Self |
Cedar Rapids |
Linn |
IA |
Adam Feldmann |
Tarin Tanner |
Signed |
386 |
2022-01-11 08:30 |
Anonymous (not verified) |
173.29.238.103 |
Brilliant All-Seasons Lighting Inc. |
10357 NW 42nd St., Polk City, IA 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2022-01-11 |
Katrina Marie Loney |
katrinaloney@outlook.com |
Polk City |
Polk |
Iowa |
Linda Delin |
Amanda Warywoda |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Brad Loney |
bloney@live.com |
President |
Polk City |
Polk |
Iowa |
Linda Delin |
Amanda Warywoda |
Signed |
107 |
2020-08-04 13:42 |
Anonymous (not verified) |
97.64.131.90 |
BNR Construction INC |
210 4th St Orient, IA 50858 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-08-04 |
Bennie Shinn |
bnrconstllc@gmail.com |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bennie Shinn |
bnrconstllc@gmail.com |
President |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
112 |
2020-08-26 10:18 |
Anonymous (not verified) |
97.64.131.90 |
BNR Construction INC |
210 4th St Orient, IA 50858 |
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. |
2020-07-15 |
Bennie Shinn |
bnrconstllc@gmail.com |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bennie Shinn |
bnrconstllc@gmail.com |
President |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
111 |
2020-08-25 14:37 |
Anonymous (not verified) |
204.155.61.217 |
BNR Construction INC |
210 4th St Orient,Ia 50858 |
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. |
2020-07-15 |
Bennie Shinn |
bnrconstructllc@gmail.com |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bennie Shinn |
bnrconstructllc@gmail.com |
President |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
231 |
2021-04-11 12:19 |
Anonymous (not verified) |
174.243.115.140 |
Blaser Plumbing Inc |
28933 Sieverding Ridge Rd Bellevue IA 52031 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-11 |
Michael Blaser |
bpi1999@hotmail.com |
Bellevue |
IA |
United States |
Joyce Langmeier |
Sylvester Langmeier |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Blaser |
bpi1999@hotmail.com |
Owner |
Bellevue |
IA |
United States |
Joyce Langmeier |
Sylvester Langmeier |
Signed |
424 |
2022-03-11 15:36 |
Anonymous (not verified) |
69.63.16.2 |
BR Flynn Co Inc |
16756 Corey Daniel Ct, Dubuque, IA 52001 |
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. |
2022-03-11 |
Bruce R Flynn |
br.flynn4@gmail.com |
Dubuque |
Dubuque |
Iowa |
Rick Meyer |
Dyan Kriener |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bruce R Flynn |
br.flynn4@gmail.com |
President |
Dubuque |
Dubuque |
IA |
Rick Meyer |
Dyan Kriener |
Signed |
91 |
2020-06-17 17:47 |
Anonymous (not verified) |
166.182.83.28 |
BJJ Painting Inc |
6940 Rolling Ridge CT 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. |
2020-06-17 |
Bradley Johnson |
brad.johnson@fivestarpainting.com |
Cedar Rapids |
Linn |
Iowa |
Mike McClure |
Tony Gaiffe |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradley Johnson |
brad.johnson@fivestarpainting.com |
President |
Cedar Rapids |
Linn |
Iowa |
Mike McClure |
Tony Gaiffe |
Signed |
844 |
2023-12-29 08:28 |
Anonymous (not verified) |
94.188.207.226 |
Emcubed Enterprises, Inc |
979 40th Ave, Bettendorf, IA 52722 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-29 |
Bradley David Morrison |
brad@riverbendsignworks.com |
Moline |
Rock Island |
IL |
David Rodriguez |
Lisbet Lule |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradley David Morrison |
brad@riverbendsignworks.com |
Owner |
Moline |
Rock Island |
IL |
David Rodriguez |
Lisbet Lule |
Signed |
862 |
2024-01-22 13:55 |
Anonymous (not verified) |
94.188.207.228 |
Emcubed Enterprises, Inc |
979 40th Ave, Bettendorf, IA 52722 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-22 |
Bradley D Morrison |
brad@riverbendsignworks.com |
Moline |
Rock Island |
IL |
Richard Henning |
Kyle Sebben |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Morrison |
brad@riverbendsignworks.com |
Owner |
Moline |
Rock Island |
IL |
Richard Henning |
Kyle Sebben |
Signed |
85 |
2020-06-03 17:53 |
Anonymous (not verified) |
75.162.69.231 |
Blackford Foundations Inc |
501 SW Franklin Dr, Ankeny, IA 50023 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-05-01 |
Brenda Marie Blackford |
brendab@blackfordfoundations.com |
Ankeny |
Polk |
Iowa |
Saree Luce |
Ricky Eatwell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brenda Marie Blackford |
brendab@blackfordfoundations.com |
President |
Ankeny |
Polk |
Iowa |
Saree Luce |
Ricky Eatwell |
Signed |