213 |
2021-03-25 15:45 |
Anonymous (not verified) |
173.20.159.129 |
Goldsmith Ventures, Inc. |
308 E. Burlington St. #183 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-25 |
Jonathan Goldsmith |
jbg789@gmail.com |
Hills |
Johnson |
Iowa |
Monica Goldsmith |
Aura Rodriguez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jonathan Goldsmith |
jbg789@gmail.com |
Owner |
Hills |
Johnson |
Iowa |
Monica Goldsmith |
Aura Rodriguez |
Signed |
169 |
2021-01-26 12:20 |
Anonymous (not verified) |
74.84.91.178 |
Sunset Ridge Winery LLC |
12615 Highway 52 North, Dubuque, 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. |
2020-12-07 |
John Bonnette |
jbonnette@yahoo.com |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John Bonnette |
jbonnette@yahoo.com |
Officer |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
170 |
2021-01-26 12:23 |
Anonymous (not verified) |
74.84.91.178 |
Sunset Ridge Winery LLC |
12615 Highway 52 North, Dubuque, 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. |
2020-12-07 |
Ann Bonnette |
jbonnette@yahoo.com |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ann Bonnette |
jbonnette@yahoo.com |
Officer |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
635 |
2023-03-23 15:43 |
Anonymous (not verified) |
94.188.207.228 |
Pacifica Health Services, LLC |
4911 SW 19th 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. |
2023-03-23 |
Kevin Babb |
kbabb@viahealthservices.com |
Waukee |
Dallas |
Iowa |
Jackie Hastings |
Amber Perdue |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jennifer Conner |
jconner@viahealthservices.com |
President |
Des Moines |
Polk |
IA |
Jackie Hastings |
Amber Perdue |
Signed |
636 |
2023-03-23 15:49 |
Anonymous (not verified) |
94.188.207.229 |
Pacifica Health Services, LLC |
4911 SW 19th 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. |
2023-03-23 |
Robert Conner |
dr.conner@metrogeriatrics.com |
Norwalk |
Warren |
Iowa |
Jackie Hastings |
Amber Perdue |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jennifer Conner |
jconner@viahealthservices.com |
President |
Des Moines |
Polk |
IA |
Jackie Hastings |
Amber Perdue |
Signed |
113 |
2020-09-03 14:22 |
Anonymous (not verified) |
72.255.74.171 |
James Raymond and Associates Inc |
240 S 1st 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. |
2020-09-03 |
Jim Downs |
jdowns@arrowisg.com |
Carlisle |
Warren |
Iowa |
TJ Cataldo |
Patti Isley |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jim Downs |
jdowns@arrowisg.com |
Owner |
Carlisle |
Warren |
Iowa |
TJ Cataldo |
Patti Isley |
Signed |
162 |
2021-01-19 15:21 |
Anonymous (not verified) |
72.255.74.171 |
JD Enterprises Inc |
4807 160th Ave, 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. |
2021-01-19 |
Jim Downs |
jdowns@arrowisg.com |
Carlisle |
Warren |
Iowa |
Tyler Cataldo |
Patti Isley |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jim Downs |
jdowns@arrowisg.com |
Owner |
Carlisle |
Warren |
Iowa |
Tyler Cataldo |
Patti Isley |
Signed |
287 |
2021-07-19 11:58 |
Anonymous (not verified) |
207.199.222.199 |
STEPHEN MEMORIAL ANIMAL SHELTER INC |
1716 Pella 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. |
2021-06-26 |
Jeanie Bieri |
jeanie.bieri@musco.com |
Oskaloosa |
Mahaska |
Iowa |
Billy Blake |
Merri Chris Hawker |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeanie Bieri |
jeanie.bieri@musco.com |
Board President |
Oskaloosa |
Mahaska |
Iowa |
Billy Blake |
Merri Chris Hawker |
Signed |
500 |
2022-06-22 15:55 |
Anonymous (not verified) |
206.125.132.254 |
Cozad Trucking Inc |
2272 W River Dr, Davenport, IA 52802 |
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. |
2022-06-22 |
David Cozad |
jeepd856@gmail.com |
Davenport |
Scott |
Iowa |
Brett Nelson |
Colleen Heiser |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Cozad |
jeepd856@gmail.com |
Owner |
Davenport |
Scott |
IA |
Brett Nelson |
Colleen Heiser |
Signed |
133 |
2020-11-15 19:57 |
Anonymous (not verified) |
75.162.166.182 |
A Metro Snow Removal and lawn care llc |
6436 Washington Ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-11-15 |
Jeff Lamp |
Jeff.lamp79@gmail.com |
Windsor hieghts |
IA |
United States |
Jill Fresh |
Rick Brown |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
A Metro Snow Removal and lawn Care llc |
Jeff.lamp79@gmail.com |
Owner |
Windsor hieghts |
IA |
United States |
jill Fresh |
Rick Brown |
Signed |
235 |
2021-04-14 13:18 |
Anonymous (not verified) |
173.31.147.225 |
HISTORIC ARNOLDS PARK INC |
37 LAKE ST ARNOLDS PARK, IA 51331 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-14 |
LANCE EVANS |
joel@walkerinsuranceia.com |
ARNOLDS PARK |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
JEFF VIERKANT |
Jeff@arnoldspark.com |
CEO |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JEFF VIERKANT |
Signed |
224 |
2021-03-29 11:26 |
Anonymous (not verified) |
174.198.71.64 |
Pro wash Dubuque inc |
1795 Atlantic st |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-28 |
Jordan John block |
prowashdubuque@gmail.com |
East Dubuque |
Jo Davis |
IL |
Abigail Ann Metcalf |
Dawn Marie block |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ludovissy insurance |
jeff@ludovissyandassociates.com |
He is my agent |
Dubuque |
Dubuque country |
IA |
Jordan John block |
Abigail Ann Metcalf |
Signed |
277 |
2021-06-17 21:34 |
Anonymous (not verified) |
97.125.98.166 |
J. Bos Holdings |
10925 NE 23rd Ave Mitchellville, IA 50169 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-06-17 |
Jeff Bos |
jeffbos1967@gmail.com |
Mitchellville |
Iowa |
United States |
Angela Bos |
Amy Bos |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeff Bos |
jeffbos1967@gmail.com |
officer |
Mitchellville |
Iowa |
United States |
Angela Bos |
Amy Bos |
Signed |
824 |
2023-11-21 13:22 |
Anonymous (not verified) |
94.188.207.227 |
OhZone. LLC |
852 Washington 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. |
2023-11-19 |
Jeffery W Ishmael |
jeffishmael@gmail.com |
Des Moines |
IA |
United States |
Juan DeLlanos |
Gregory Gunter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffery W Ishmael |
jeffishmael@gmail.com |
Co-Owner |
Des Moines |
IA |
United States |
Juan DeLlanos |
Gregory Gunter |
Signed |
563 |
2022-11-09 10:28 |
Anonymous (not verified) |
199.168.243.195 |
Mensingers Aquatic Resources, Inc. |
2119 Oak Trail Drive |
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. |
2022-11-09 |
Jeff Mensinger |
jeffrey.mensinger@hdrinc.com |
Camanche |
ia |
United States |
Cody Mensinger |
Jeremiah Haas |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeff Mensinger |
jeffrey.mensinger@hdrinc.com |
President |
Camanche |
ia |
United States |
Cody Mensinger |
Jeremiah Haas |
Signed |
60 |
2020-04-20 13:06 |
Anonymous (not verified) |
173.24.181.211 |
Historic Arnolds Park Inc |
37 Lake Street, PO Box 609, Arnolds Park, IA 51331 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-01 |
Charley Whittenburg |
jennifer@walkerinsuranceia.com |
Spencer |
Clay |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Charley Whittenburg |
jennifer@walkerinsuranceia.com |
Vice President |
Spencer |
Clay |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
61 |
2020-04-20 13:13 |
Anonymous (not verified) |
173.24.181.211 |
Historic Arnolds Park Inc |
37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-01 |
Bruce Tamisiea |
jennifer@walkerinsuranceia.com |
Wahpeton |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bruce Tamisiea |
jennifer@walkerinsuranceia.com |
Board Member |
Wahpeton |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
62 |
2020-04-20 13:18 |
Anonymous (not verified) |
173.24.181.211 |
Historic Arnolds Park Inc |
37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-01 |
Ron Morocco |
jennifer@walkerinsuranceia.com |
Milford |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ron Morocco |
jennifer@walkerinsuranceia.com |
Board Member |
Milford |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
63 |
2020-04-20 13:23 |
Anonymous (not verified) |
173.24.181.211 |
Historic Arnolds Park Inc |
37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-01 |
Suzie Wilmot |
jennifer@walkerinsuranceia.com |
Minneapolis |
Hennepin |
Minnesota |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Suzie Wilmot |
jennifer@walkerinsuranceia.com |
Board Member |
Minneapolis |
Hennepin |
Minnesota |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
64 |
2020-04-20 13:30 |
Anonymous (not verified) |
173.24.181.211 |
Historic Arnolds Park Inc |
37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-01 |
Mike Bennett |
jennifer@walkerinsuranceia.com |
Jefferson |
Union |
South Dakota |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mike Bennett |
jennifer@walkerinsuranceia.com |
Treasurer |
Jefferson |
Union |
South Dakota |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
65 |
2020-04-20 13:37 |
Anonymous (not verified) |
173.24.181.211 |
Historic Arnolds Park Inc |
37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-01 |
Denny Walker |
jennifer@walkerinsuranceia.com |
West Okoboji |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Denny Walker |
jennifer@walkerinsuranceia.com |
Board Member |
West Okoboji |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
66 |
2020-04-20 13:41 |
Anonymous (not verified) |
173.24.181.211 |
Historic Arnolds Park Inc |
37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-01 |
Tresa Hussong |
jennifer@walkerinsuranceia.com |
Arnolds Park |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tresa Hussong |
jennifer@walkerinsuranceia.com |
Board Member |
Arnolds Park |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
67 |
2020-04-20 13:46 |
Anonymous (not verified) |
173.24.181.211 |
Historic Arnolds Park Inc |
37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-01 |
John Franken |
jennifer@walkerinsuranceia.com |
Spirit Lake |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John Franken |
jennifer@walkerinsuranceia.com |
Vice President |
Spirit Lake |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
68 |
2020-04-20 13:50 |
Anonymous (not verified) |
173.24.181.211 |
Historic Arnolds Park Inc |
37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-01 |
Jill Harms |
jennifer@walkerinsuranceia.com |
Milford |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jill Harms |
jennifer@walkerinsuranceia.com |
President |
Milford |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
70 |
2020-04-21 10:29 |
Anonymous (not verified) |
173.24.181.211 |
Mr. Drain Man LLC |
607 36th Street, Spirit Lake IA 51360 |
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. |
2020-04-21 |
Jan Coon |
jennifer@walkerinsuranceia.com |
Spirit Lake |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mr Drain Man LLC |
jennifer@walkerinsuranceia.com |
Member |
Spirit Lake |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
879 |
2024-02-02 15:24 |
Anonymous (not verified) |
94.188.205.169 |
Open Road Driving School.com INC |
2418 Paradise Ct Kalona, Iowa 52247 |
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. |
2024-02-02 |
Jennifer Turner |
jenny@openroaddrivingschool.com |
Kalona |
Washington |
Iowa |
Lonnie Slabaugh |
Joshua Turner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jennifer Turner |
jenny@openroaddrivingschool.com |
president |
Kalona |
Washington |
Iowa |
Lonnie Slabaugh |
Joshua Turner |
Signed |
559 |
2022-10-24 15:14 |
Anonymous (not verified) |
108.178.192.251 |
LogicBox, Inc. |
2381 Highway 169, Winterset, IA 50273 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-10-24 |
Jeremy Goemaat |
jeremy.goemaat@gmail.com |
Winterset |
Madison |
Iowa |
Janelle Goemaat |
Gunnar Goemaat |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeremy Goemaat |
jeremy.goemaat@gmail.com |
CEO/Owner |
Winterset |
Madison |
Iowa |
Janelle Goemaat |
Gunnar Goemaat |
Signed |
329 |
2021-09-08 10:18 |
Anonymous (not verified) |
206.80.128.71 |
H F Corporation |
105 E Oskaloosa Pella, IA 50219 |
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. |
2021-09-08 |
Bharat Patel |
super8pella@gmail.com |
Pella |
Marion |
Iowa |
Mark Chambers |
Jim Wessels |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeremy Rogstad |
jeremy@jeremyrogstad.com |
State Farm Agent |
Iowa |
Floyd |
Iowa |
Mark Chambers |
Jim Wessels |
Signed |
330 |
2021-09-08 10:20 |
Anonymous (not verified) |
206.80.128.71 |
H F Corporation |
105 Oskaloosa St Pella, IA 50219 |
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. |
2021-09-08 |
Nayan Patel |
super8pella@gmail.com |
Pella |
Marion |
Iowa |
Mark Chambers |
Jim Wessels |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeremy Rogstad |
jeremy@jeremyrogstad.com |
State Farm Agent |
Charles City |
Floyd |
Iowa |
Mark Chambers |
Jim Wessels |
Signed |
331 |
2021-09-08 10:21 |
Anonymous (not verified) |
206.80.128.71 |
H F Corporation |
105 Oskaloosa St Pella, IA 50219 |
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. |
2021-09-08 |
Dinesh Patel |
super8pella@gmail.com |
Pella |
Marion |
Iowa |
Mark Chambers |
Jim Wessels |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeremy Rogstad |
jeremy@jeremyrogstad.com |
State Farm Agent |
Charles City |
Floyd |
Iowa |
Mark Chambers |
Jim Wessels |
Signed |
493 |
2022-06-08 13:00 |
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. |
2022-06-06 |
JESSICA SCHABLE |
JESS@OKOBOJIPERFORMINGARTS.COM |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
JESSICA SCHABLE |
JESS@OKOBOJIPERFORMINGARTS.COM |
SELF |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
315 |
2021-08-19 13:08 |
Anonymous (not verified) |
173.26.33.84 |
CLINK FM, Inc. |
110 N. Maryville 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. |
2021-08-19 |
Kyana B Taillon |
kyanalily@gmail.com |
Oelwein |
Fayette |
IA |
Della Nehring |
Tim Nehring |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jesse Y Goplen |
jesse@clink.fm |
Co-Founder/President |
Oelwein |
Fayette |
IA |
Della Nehring |
Tim Nehring |
Signed |
710 |
2023-07-21 08:26 |
Anonymous (not verified) |
94.188.205.169 |
Dream Team Anesthesia, Inc. |
2800 E. Enterprise Ave, Ste 333, Appleton, WI 54913 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-07-21 |
Jesse Chiu |
jessechiu2@yahoo.com |
Sterling |
Whiteside |
IL |
Joseph Chiu |
Kin Chiu |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jesse Chiu |
jessechiu2@yahoo.com |
President |
Waterloo |
Polk |
Iowa |
Joseph Chiu |
Kin Chiu |
Signed |
41 |
2020-02-16 19:09 |
Anonymous (not verified) |
207.199.193.217 |
S J Hernandez, Inc |
19738 133rd Street Bloomfield, IA 52537 |
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. |
2020-02-16 |
Jessica Hernandez |
jessieatcjs@gmail.com |
Bloomfield |
Davis |
Iowa |
Salvador Hernandez-Perez |
Joseph Olinger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jessica Hernandez |
jessieatcjs@gmail.com |
Owner |
Bloomfield |
Davis |
Iowa |
Salvador Hernandez-Perez |
Joseph Olinger |
Signed |
42 |
2020-02-16 19:13 |
Anonymous (not verified) |
207.199.193.217 |
S J Hernandez, Inc |
19738 133rd Street Bloomfield, IA 52537 |
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. |
2020-02-16 |
Salvador Hernandez-Perez |
jessieatcjs@gmail.com |
Bloomfield |
Davis |
Iowa |
Jessica Hernandez |
Joseph Olinger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Salvador Hernandez-Perez |
jessieatcjs@gmail.com |
Owner |
Bloomfield |
Davis |
Iowa |
Jessica Hernandez |
Joseph Olinger |
Signed |
698 |
2023-06-21 07:46 |
Anonymous (not verified) |
94.188.207.223 |
Jesus Rodriguez |
2210 E. Rose Avenue Apt. 30 Des Moines, Iowa 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. |
2023-06-21 |
Jesus Rodriguez |
jesus.jr4514@gmail.com |
Des Moines |
Polk |
Iowa |
Veronica Rodriguez |
Daniel Gallardo |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jesus Rodriguez |
jesus.jr4514@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Veronica Rodriguez |
Daniel Gallardo |
Signed |
540 |
2022-09-22 18:48 |
Anonymous (not verified) |
172.58.84.145 |
José j Castañeda lara |
1722 22st Des Moines iowa 50310 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-09-22 |
José j Castañeda lara |
jesuscastaneda28@gmail.com |
Des Moines |
Polk |
Iowa |
Joseph Powell |
Jesica Powell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
José j Castañeda lara |
jesuscastaneda28@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Joseph Powell |
Jesica Powell |
Signed |
858 |
2024-01-18 08:24 |
Anonymous (not verified) |
94.188.207.226 |
Custom Flooring LLC |
7085 Bloomfield Road Lot 249 Des Moines, Iowa 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. |
2024-01-18 |
Jesus Vera |
jesusvera199027@icloud.com |
Des Moines |
Polk |
Iowa |
Natalia Vera |
Adriana de Anda |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jesus Vera |
jesusvera199027@icloud.com |
Owner |
Des Moines |
Polk |
Iowa |
Natalia Vera |
Adriana de Anda |
Signed |
333 |
2021-09-14 14:53 |
Anonymous (not verified) |
147.0.156.50 |
O'Danny Boy Builders, Inc. |
7512 S. County Line Rd., Suite #4, Burr Ridge, IL 60527 |
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. |
2021-09-14 |
Daniel Flanagan |
jflanagan@odannyboybuilders.com |
LaGrange |
Cook |
Illinois |
John Flanagan |
Mark Hayes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John Flanagan |
Jflanagan@odannyboybuilders.com |
Executive |
Western Springs |
Cook |
IL |
Ben Weed |
Mark Hayes |
Signed |
868 |
2024-01-25 14:08 |
Anonymous (not verified) |
94.188.207.229 |
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. |
2024-01-25 |
Trevor McCauley |
jhawktm@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Bridget |
Camp |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Trevor McCauley |
jhawktm@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Bridget Camp |
Trevor McCauley |
Signed |
871 |
2024-01-26 09:16 |
Anonymous (not verified) |
94.188.205.168 |
NeX Level Restoration |
314 8th St NW, 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. |
2024-01-26 |
Trevor McCauley |
jhawktm@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Bridget Camp |
Bridget Camp |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Trevor McCauley |
jhawktm@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Bridget Camp |
Bridget Camp |
Signed |
80 |
2020-05-11 12:29 |
Anonymous (not verified) |
173.191.207.202 |
J&D Furniture-Land Corp |
144 1st Ave East - Dyersville, IA 52040 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-05-07 |
Scott Hittenmiller |
dparsons@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
agent-English Insurance |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
82 |
2020-05-18 15:16 |
Anonymous (not verified) |
184.80.177.137 |
Farmers Best Popcorn, LLC |
110 1st Street North, - Worthington, IA 52078 |
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. |
2020-05-18 |
Jon Ramaekers |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
self |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
103 |
2020-07-23 09:23 |
Anonymous (not verified) |
184.80.177.137 |
Jacob Reiff |
15738 N Cascade Rd - Peosta, IA 52068 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2020-07-23 |
Jacob Reiff |
jheims@engish-insurance.com |
Peosta, |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
owner |
Peosta |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
279 |
2021-06-23 10:41 |
Anonymous (not verified) |
184.80.177.137 |
AA Breeders |
P.O. Box 470 - Epworth, IA 52045 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-06-22 |
Justin Curtis |
jheims@english-insurance.com |
Epworth |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
AA Breeders - Justin Curtis |
jheims@english-insurance.com |
self |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
384 |
2022-01-06 16:01 |
Anonymous (not verified) |
184.80.177.137 |
Top R Farms |
1199 Woodland Drive - 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. |
2022-01-06 |
Robert Fangmann |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
388 |
2022-01-11 13:58 |
Anonymous (not verified) |
184.80.177.137 |
Demmer Construction |
203 Michigan Ave - 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. |
2021-12-21 |
Charlie Demmer |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jenny Osburn |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
389 |
2022-01-11 14:02 |
Anonymous (not verified) |
184.80.177.137 |
Demmer Construction |
203 Michigan Ave - 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. |
2021-05-12 |
Charlie Demmer |
jheims@english-insurance.com |
Farley |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jenny Osburn |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
436 |
2022-03-29 11:07 |
Anonymous (not verified) |
184.80.177.137 |
Adam Sheppard |
22194 260th St - Delhi, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-24 |
Adam Sheppard |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam Sheppard |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
455 |
2022-04-27 14:04 |
Anonymous (not verified) |
184.80.177.137 |
Classic Custom Cabinets, Inc |
31931 Bries Drive , 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. |
2022-04-27 |
Mike Then |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |