859 |
2024-01-19 06:38 |
Anonymous (not verified) |
94.188.205.166 |
D & G Communications |
405 1st Street N. Farley, Iowa 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. |
2024-01-19 |
David William Hirsch |
dngcomm@hotmail.com |
Farley |
Dubuque |
Iowa |
Gina Hirsch |
Micki Jones |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dave Hirsch |
dngcomm@hotmail.com |
Owner |
Farley |
Dubuque |
Iowa |
Gina Hirsch |
Micki Jones |
Signed |
145 |
2020-12-18 07:54 |
Anonymous (not verified) |
173.215.16.15 |
Dohrmann Enterprises Inc |
2652 350th Ave DeWitt, IA 52742 |
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. |
2020-12-18 |
Tom Dohrmann |
dohrmannpnh@gmail.com |
DeWitt |
Clinton |
Iowa |
Susanne Owen |
Daron Oberbroeckling |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tom Dohrmann |
dohrmannpnh@gmail.com |
Owner |
DeWitt |
Clinton |
Iowa |
Susanne Owen |
Daron Oberbroeckling |
Signed |
872 |
2024-01-26 10:28 |
Anonymous (not verified) |
94.188.205.177 |
Sole proprietor- Dennis R. Oliver dba Olivers Oasis Communications |
150 Spring Valley Ct. Springtown, TX 76082 |
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. |
2024-01-26 |
Dennis Reeves Oliver |
doliversoasis@aol.com |
Springtown |
Parker |
Texas |
Helen Frances Steil |
John Kevin Steil |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dennis Reeves Oliver |
doliversoasis@aol.com |
Self |
Springtown |
Parker |
TX |
Helen Frances Steil |
John Kevin Steil |
Signed |
263 |
2021-05-06 15:18 |
Anonymous (not verified) |
174.243.113.232 |
Agronomic Solutions |
908 E Dubuque St Quasqueton IA 52326 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-06 |
Brandy Hodges |
mapping@agsolutionsinc.net |
Coon Rapids |
IA |
United States |
Jacki Sloss |
Don Sloss |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Friday Insurance |
doug.miller@fridayinsurance.net |
agent |
Osceola |
Clarke |
IA |
Jacki Sloss |
Don Sloss |
Signed |
966 |
2024-04-30 14:39 |
Anonymous (not verified) |
94.188.207.230 |
Bowman Dozing & Excavating LLC |
218 134th ave 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. |
2024-04-30 |
Bradley D Bowman |
dozermann9@hotmail.com |
Maquoketa |
Jackson |
Iowa |
Jennifer Machande |
Mitchell Schaller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradley D Bowmann |
dozermann9@hotmail.com |
owner/president |
maquoketa |
Jackson |
iowa |
Jennifer Machande |
Mitch Schaller |
Signed |
76 |
2020-05-04 10:24 |
Anonymous (not verified) |
173.191.207.202 |
Tim Fitzgerald Mechanical Services, Inc. |
724 1st Ave W - 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. |
2020-04-24 |
Tim Fitzgerald |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
agent-English Insurance |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
108 |
2020-08-19 09:39 |
Anonymous (not verified) |
184.80.177.137 |
Michelle's Vocational Placement LLC |
2642 Farragut Pl., Davenport, IA 52804 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-08-18 |
Tara Rommel |
jheims@engish-insurance.com |
Davenport |
Scott |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
129 |
2020-10-30 11:23 |
Anonymous (not verified) |
184.80.177.137 |
Haberdash Outfitters, Inc. |
109 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. |
2020-10-27 |
Jennifer Recker |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
396 |
2022-02-01 10:03 |
Anonymous (not verified) |
184.80.177.137 |
LKB Holdings, LLC |
P.O. box 313 - Monona, Ia 52159 |
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. |
2022-01-29 |
Kandi Gillitzer |
jheims@english-insurance.com |
Monoa |
Clayton |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
self |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
413 |
2022-02-23 16:31 |
Anonymous (not verified) |
184.80.177.137 |
T-Rex Hospitality LLC, DBA FUSE |
120 Twin Steeples Circle, Dyersville Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-02-23 |
Tara Rahe |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
448 |
2022-04-19 15:15 |
Anonymous (not verified) |
184.80.177.137 |
Andrew Lemke DBA: TAP Fabrication |
27214 218th Street, Earlville, IA 52041 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-04-08 |
Andrew Lemke |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
515 |
2022-07-19 10:06 |
Anonymous (not verified) |
184.80.177.137 |
Mom Clean, LLC |
4 East 3rd Street - Earlville, IA 52041 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-07-18 |
Morgan Lahr |
dparsons@english-insurance.com |
Dyersville |
Delaware |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
self |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
541 |
2022-09-23 13:13 |
Anonymous (not verified) |
184.80.177.137 |
Tim & Lori Daly |
25430 New Vienna Rd - 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. |
2022-09-23 |
Tim Daly |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
agent |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
542 |
2022-09-26 19:26 |
Anonymous (not verified) |
45.78.142.139 |
Doyle Vondrak Trucking |
315 Vermont Avenue, Kingsley, Iowa 51028 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-09-26 |
Doyle P Vondrak |
dpvondrak@wiatel.net |
Kingsley |
Plymouth |
Iowa |
Jayne R Vondrak |
Jesse M Vondrak |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Doyle P Vondrak |
dpvondrak@wiatel.net |
self-employed; single employee |
Kingsley |
Plymouth |
Iowa |
Jayne R Vondrak |
Jesse M Vondrak |
Signed |
495 |
2022-06-08 13:07 |
Anonymous (not verified) |
173.31.148.43 |
OKOBOJI PERFORMING ARTS |
97 WOODLIN DR MILFORD, IA 51351 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-08 |
DREW DUNCAN |
DREW@OKOBOJIPERFORMINGARTS.COM |
LINCOLN |
LANCASTER |
NE |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
DREW DUNCAN |
DREW@OKOBOJIPERFORMINGARTS.COM |
SELF |
LINCOLN |
LANCASTER |
NE |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
941 |
2024-04-03 10:26 |
Anonymous (not verified) |
94.188.207.223 |
Andrew Renna |
407 19th st spirit lake Iowa 51369 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-03 |
Andrew John Renna |
drewrenna86@gmail.com |
Spirit lake |
Dickinson |
Iowa |
Brianna Lene |
Nicholas Omang |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andrew Renna |
drewrenna86@gmail.com |
Owner |
Spirit lake |
Dickinson |
Iowa |
Brianna Lene |
Nicholas Omang |
Signed |
55 |
2020-04-06 16:25 |
Anonymous (not verified) |
74.221.44.37 |
Steele Land & Livestock, Inc |
1040 190th St, Anita, IA 50020 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-06 |
Doug Steele |
dsteele@midlands.net |
Anita |
Adair |
Iowa |
Sheryl Leonard |
Cheryl Ellis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Doug Steele |
dsteele@midlands.net |
President |
Anita |
Adair |
Iowa |
Sheryl Leonard |
Cheryl Ellis |
Signed |
168 |
2021-01-26 12:06 |
Anonymous (not verified) |
74.84.91.178 |
RAM Services |
13276 Harvest Mood Ridge, Sherrill, IA 52073 |
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. |
2020-12-11 |
Dusty Herbst |
dustyherbst@hotmail.com |
Sherrill |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dusty Herbst |
dustyherbst@hotmail.com |
President |
Sherrill |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
632 |
2023-03-22 13:44 |
Anonymous (not verified) |
94.188.205.177 |
Midwest Home Solutions Inc |
150 Light Rd., Lisbon, IA 52253 |
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. |
2023-03-22 |
Ean Michael Caskey |
ean_caskey@hotmail.com |
Lisbon |
Linn |
IA |
Trista Leigh Schaffner |
Christopher Ray Schaffner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ean Michael Caskey |
ean_caskey@hotmail.com |
President |
Lisbon |
Linn |
Iowa |
Trista Leigh Schaffner |
Christopher Ray Schaffner |
Signed |
478 |
2022-05-24 13:16 |
Anonymous (not verified) |
63.146.149.12 |
EBN CONSTRUCTION LLC |
314 NE 5TH ST, ANKENY IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-24 |
Juan J Perez Munoz |
ebnconstruction@icloud.com |
Des Moines |
Polk |
Iowa |
Jaime Leiva |
Kevin Pham |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Juan J Perez Munoz |
ebnconstruction@icloud.com |
Owner |
Des MOines |
Polk |
Iowa |
Jaime Leiva |
Kevin Pham |
Signed |
132 |
2020-11-03 13:22 |
Anonymous (not verified) |
173.22.125.16 |
BeraTek Industries |
407 9th Ave SE, Cedar Rapids, IA 52401 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-11-03 |
Ethan Davidson |
edavidson@beratek-industries.com |
Cedar Rapids |
Linn |
Iowa |
Raymond Gerald Beranek |
Ethan Paul Davidson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ethan Paul Davidson |
edavidson@beratek-industries.com |
President |
Cedar Rapids |
Linn |
Iowa |
Raymond Gerald Beranek |
Ethan Paul Davidson |
Signed |
118 |
2020-09-15 14:32 |
Anonymous (not verified) |
174.243.115.133 |
Jurisdiction Approved Plumbing Corporation |
P.O. Box 343 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-09-15 |
Christian m Lavia |
eeejumble@gmail.com |
Urbandale |
Polk |
Iowa |
Tina m Heuckendorf |
Roslyn Heuckendorf |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christian m Lavia |
eeejumble@gmail.com |
Director |
Urbandale |
Polk |
IOWA |
Tina m Heuckendorf |
Roslyn Heukendorf |
Signed |
226 |
2021-04-01 11:52 |
Anonymous (not verified) |
97.125.87.4 |
JK Holdings |
1300 NW 100TH ST. Suite 3000 Clive, IA 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-01 |
Joey Boyens |
ekindesmoines@gmail.com |
Clive |
Polk |
Iowa |
Jenae Halstead |
Cam Naylor |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jenae Halstead |
ekindesmoines@gmail.com |
Manager |
Clive |
Polk |
Iowa |
Joey Boyens |
Cam Naylor |
Signed |
59 |
2020-04-14 12:54 |
Anonymous (not verified) |
65.126.161.162 |
Elite Carpentry |
1515 21st Street 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. |
2020-04-10 |
Jeffrey D. Leech |
elitecarpentryqc@gmail.com |
Bettendorf |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Jeffrey D. Leech |
elitecarpentryqc@gmail.com |
President |
Bettendorf |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
148 |
2020-12-30 08:22 |
Anonymous (not verified) |
166.181.83.201 |
Elite Carpentry |
P.O. Box 1162 Bettendorf Iowa 52722 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-30 |
Jeffrey D Leech |
Elitecarpentryqc@gmail.com |
Bettendorf |
Scott |
Iowa |
Jeremy Havens |
Michael Rodriguez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffrey D Leech |
Elitecarpentryqc@gmail.com |
Owner |
Bettendorf |
Scott |
Iowa |
Jeremy Havens |
Michael Rodriguez |
Signed |
778 |
2023-10-02 10:15 |
Anonymous (not verified) |
94.188.205.166 |
Medinas Tile |
2365 267th Street Oskaloosa, Iowa 52577 |
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 |
Leon Medinas |
elleonmedina@hotmail.com |
Oskaloosa |
Mahaska |
Iowa |
Rocio Medinas |
Manuel Lopez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Leon Medina |
elleonmedina@hotmail.com |
Owner |
Oskaloosa |
Mahaska |
Iowa |
Rocio Medina |
Manuel Lopez |
Signed |
851 |
2024-01-14 15:40 |
Anonymous (not verified) |
94.188.205.169 |
B St. Construction + Design, Inc. |
16 Southwest 42nd 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. |
2024-01-13 |
Emily Renze-Crouch |
emily@bstdesigner.com |
Des Moines |
Iowa |
United States |
Jodi Essex |
Linda K Renze |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Emily Renze-Crouch |
emily@bstdesigner.com |
Vice President / CFO |
Des Moines |
IA |
United States |
Jodi Essex |
Linda K Renze |
Signed |
936 |
2024-03-30 16:41 |
Anonymous (not verified) |
94.188.205.176 |
Rhubarb Botanicals LLC |
650 Martelle Rd, Springville IA 52336 |
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. |
2024-03-30 |
Emma Barber |
emma@rhubarbbotanicals.com |
Springville |
Linn |
Iowa |
Lena Wilhelm |
Harvey Wilhelm |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Emma Barber |
emma@rhubarbbotanicals.com |
Co-Owner |
Springville |
Linn |
Iowa |
Lena Wilhelm |
Harvey Wilhelm |
Signed |
673 |
2023-05-23 07:07 |
Anonymous (not verified) |
94.188.207.224 |
Mulgrew Seamless Gutters |
12 REMINGTON PARK CIR east dubuque Illinois 61025 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-05-22 |
Edward mulgrew |
Emulgrew78@gmail.com |
East Dubuque |
Jo Davis |
Illinois |
Mike Venable |
Claudia Venable |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Edward mulgrew |
Emulgrew78@gmail.com |
Owner |
East Dubuque |
Jo Davis |
Illinois |
Edward mulgrew |
Edward c mulgrew |
Signed |
674 |
2023-05-23 07:08 |
Anonymous (not verified) |
94.188.207.223 |
Mulgrew Seamless Gutters |
12 REMINGTON PARK CIR east dubuque Illinois 61025 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-05-22 |
Edward mulgrew |
Emulgrew78@gmail.com |
East Dubuque |
Jo Davis |
Illinois |
Mike Venable |
Claudia Venable |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Edward mulgrew |
Emulgrew78@gmail.com |
Owner |
East Dubuque |
Jo Davis |
Illinois |
Edward mulgrew |
Edward c mulgrew |
Signed |
581 |
2022-12-09 11:23 |
Anonymous (not verified) |
74.84.79.78 |
Avila Gutters |
5901 SW 5th St. Des Moines, IA 50315 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-01 |
Enrique Avila Ceballos |
enrique86avila@gmail.com |
Des Moines |
Polk |
Iowa |
Michael O'Conner |
Ron Rand |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Enrique Avila Ceballos |
enrique86avila@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Michael O'Conner |
Ron Rand |
Signed |
440 |
2022-03-29 20:05 |
Anonymous (not verified) |
174.215.228.20 |
Navarro construction |
2825 SE 14th St lot #6 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-29 |
Enrique Navarro |
enriquenavarro887@gmail.com |
Des Moines |
Polk |
IA |
Alondra Navarro |
René Navarro |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Enrique Navarro |
enriquenavarro884@gmail.com |
Owner |
Des moines |
Polk |
IA |
Alondra Navarro |
René Navarro |
Signed |
876 |
2024-01-30 17:55 |
Anonymous (not verified) |
94.188.207.230 |
Erik Mortens |
9823 nw 46th ct polk city iowa 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. |
(1) I reject the employers’ liability coverage. |
2024-01-30 |
Erik mortens |
Erik.mortens@gmail.com |
Polk city |
Polk |
Iowa |
Andrea Davis |
Kali Davis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik mortens |
Erik.mortens@gmail.com |
Self |
Polk city |
Polk |
Iowa |
Kali Davis |
Andrea Davis |
Signed |
877 |
2024-01-30 17:58 |
Anonymous (not verified) |
94.188.207.230 |
Erik Mortens |
9823 nw 46th ct polk city iowa 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. |
(1) I reject the employers’ liability coverage. |
2024-01-30 |
Steffanie Mortens |
steffanie.mortens@gmail.com |
Polk city |
Polk |
Iowa |
Andrea Davis |
Kali Davis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik mortens |
Erik.mortens@gmail.com |
Self |
Polk city |
Polk |
Iowa |
Kali Davis |
Andrea Davis |
Signed |
345 |
2021-10-11 15:36 |
Anonymous (not verified) |
173.188.10.36 |
Outdoor Pros LLC |
4525 HWY 22 SE |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-11 |
Erik Scott Alberhasky |
erikalberhas@gmail.com |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik Scott Alberhasky |
erikalberhas@gmail.com |
Owner |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
971 |
2024-05-03 07:33 |
Anonymous (not verified) |
94.188.205.176 |
Outdoor Pros LLC |
6535 WAPSI AVE SE Lone Tree IA 52755 |
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 |
Erik Alberhasky |
erikalberhas@gmail.com |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik Alberhasky |
erikalberhas@gmail.com |
Owner |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
972 |
2024-05-03 07:35 |
Anonymous (not verified) |
94.188.205.175 |
Outdoor Pros LLC |
6535 WAPSI AVE SE Lone Tree IA 52755 |
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 |
Erik Alberhasky |
erikalberhas@gmail.com |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik Alberhasky |
erikalberhas@gmail.com |
Owner |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
398 |
2022-02-01 18:50 |
Anonymous (not verified) |
172.58.83.243 |
essential renovation LLC |
516 e center st, freeport il |
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. |
2022-02-01 |
teodoro jimenez |
essentialrenovations.llc@gmail.com |
freeport |
stephenson |
il |
adam spear |
karly spear |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
sandra cuatlatl |
essentialrenovations.llc@gmail.com |
owner |
freeport |
stephenson |
il |
adam spear |
karly spear |
Signed |
186 |
2021-02-24 14:35 |
Anonymous (not verified) |
216.51.194.37 |
Estherville Aviation, Inc. |
1672 425th Ave, Estherville, IA 51334 |
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. |
2021-02-24 |
Paul Abrams Slaughter |
estavtn@yourstarnet.net |
Estherville |
Emmet |
Iowa |
Jordan Lampman |
Dwayne Hoss |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Abrams Slaughter |
estavtn@yourstarnet.net |
President |
Estherville |
Emmet |
Iowa |
Jordan Lampman |
Dwayne Hoss |
Signed |
753 |
2023-08-21 14:21 |
Anonymous (not verified) |
94.188.205.174 |
NexLevelMoving |
1186 Capital Dr Sw, Cedar Rapids |
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. |
2023-08-23 |
Ethan Daniel Sailer |
ethan.sailer@hscsi.net |
Cedar Rapids |
Linn County |
Iowa |
Penny Sailer |
Denis Sailer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ethan Daniel Sailer |
ethan.sailer@hscsi.net |
Self |
Cedar Rapids |
Linn County |
Iowa |
Penny Sailer |
Denis Sailer |
Signed |
280 |
2021-06-29 16:51 |
Anonymous (not verified) |
50.83.167.103 |
King Kleen LLC |
421 S. 6th Street, Burlington, IA 52601 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-06-29 |
Heidi King |
Kingbizsol@gmail.com |
Burlington |
Des Moines |
Iowa |
Ethan King |
Bob King |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Heidi King |
ethan@kingkleen.biz |
Owner |
Burlington |
Des Moines |
Iowa |
Ethan King |
Robert King |
Signed |
300 |
2021-08-03 12:43 |
Anonymous (not verified) |
97.125.35.240 |
Every Solutions Drywall INC |
713 SE 7th St Des Moines, Iowa 50309 |
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. |
2021-08-03 |
Luis Hernandez |
everysolutiondrywainc@yahoo.com |
Des Moines |
Polk |
Iowa |
Kelly Denger |
Debra Stratton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Luis Hernandez |
everysoloutiondrywainc@yahoo.com |
Owner |
Des Moines |
Polk |
Ia |
Kelly Denger |
Debra Stratton |
Signed |
429 |
2022-03-24 13:37 |
Anonymous (not verified) |
174.255.1.155 |
Franky's Construction |
1419 Acacia Dr NE, Cedar Rapids, IA 52402 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-24 |
Frank Ackley |
fackley1981@gmail.com |
Cedar Rapids |
Linn |
IA |
Rick Deneve |
Kailee Carstensen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Franky Ackley |
fackley1981@gmail.com |
Owner |
Cesar Rapids |
Linn |
IA |
Rick DeNeve |
Kailee Carstensen |
Signed |
430 |
2022-03-24 14:47 |
Anonymous (not verified) |
173.30.76.116 |
Franky's Construction |
1419 Acacia Dr NE, Cedar Rapids, IA 52402 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-24 |
Franky Ackley |
fackley1981@gmail.com |
Cedar Rapids |
Linn |
IA |
Rick DeNeve |
Kailee Carstensen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Franky Ackley |
fackley1981@gmail.com |
Owner |
Cedar Rapids |
Linn |
IA |
Rick DeNeve |
Kailee Carstensen |
Signed |
600 |
2023-02-16 16:06 |
Anonymous (not verified) |
94.188.207.225 |
Friday After Work LLC |
2526 Rainbow Drive, Cedar Falls, IA 50613 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-01 |
Joshua Carder |
josh.cve@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Brady Huls |
Tyler Reynolds |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brent Dunlop |
fawconstruction.ia@gmail.com |
Owner |
Cedar Falls |
Black Hawk |
Iowa |
Brady Huls |
Tyler Reynolds |
Signed |
601 |
2023-02-16 16:08 |
Anonymous (not verified) |
94.188.207.223 |
Friday After Work LLC |
2526 Rainbow Drive, Cedar Falls, IA 50613 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-01 |
Tyler Reynolds |
tyler.cve@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Brady Huls |
Joshua Carder |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brent Dunlop |
fawconstruction.ia@gmail.com |
Owner |
Cedar Falls |
Black Hawk |
Iowa |
Brady Huls |
Joshua Carder |
Signed |
602 |
2023-02-16 16:10 |
Anonymous (not verified) |
94.188.207.228 |
Friday After Work LLC |
2526 Rainbow Drive, Cedar Falls, IA 50613 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-01 |
Brady John Huls |
brady.cve@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Tyler Reynolds |
Joshua Carder |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brent Dunlop |
fawconstruction.ia@gmail.com |
Owner |
Cedar Falls |
Black Hawk |
Iowa |
Tyler Reynolds |
Joshua Carder |
Signed |
20 |
2019-12-30 09:39 |
Anonymous (not verified) |
207.191.194.182 |
LA Trends Addict Inc |
1200 N CENTER POINT RD |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-10-07 |
Laura Frey |
fcrentals1@gmail.com |
HIAWATHA |
Linn |
IA |
Traci Lyons |
Allie DeVore |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Laura Frey |
fcrentals1@gmail.com |
Owner |
HIAWATHA |
Linn |
IA |
Traci Lyons |
Allie DeVore |
Signed |
684 |
2023-06-13 08:54 |
Anonymous (not verified) |
94.188.207.223 |
Sai Ram |
123 jjj |
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. |
2023-06-01 |
Jane Do |
heather@sfmic.com |
Crystal |
Minnesota |
United States |
Jane Do |
Jane |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
jkl |
fdaf@gmail.com |
fdas |
fdas |
fads |
fad |
afde |
fads |
Signed |
848 |
2024-01-05 13:05 |
Anonymous (not verified) |
94.188.205.177 |
NeX Level Moving, LLC |
5634 Deerwood St. 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. |
2024-01-05 |
William J Feldmann |
feldmannwng@msn.com |
Anamosa |
Jones |
Iowa |
Bridget |
Camp |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William J Feldmann |
feldmannwng@msn.com |
Self |
Anamosa |
Jones |
Iowa |
Bridget |
Camp |
Signed |