609 |
2023-02-22 18:56 |
Anonymous (not verified) |
94.188.205.174 |
Roman construction |
3214 se 20th st, 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. |
(2) I decline to reject the employer’s liability coverage. |
2023-02-22 |
Jonathan roman |
romanconstruction21@outlook.com |
Des moines |
Polk |
Iowa |
Jonathan Roman |
Perla Roman |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Jonathan Roman |
romanconstruction21@outlook.com |
Owner |
Des moines |
Polk |
Iowa |
Jonathan roman |
Perla roman |
Signed |
613 |
2023-02-27 14:19 |
Anonymous (not verified) |
94.188.205.169 |
Kevin Moore Professional Carpentry |
2000 s. 16th st Burlington iowa 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. |
2023-02-27 |
Keivn W. Moore |
imkwmoore@gmail.com |
Burlington |
Des Moines |
Iowa |
Kevin Moore |
DeeAnn Howard |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kevin W Moore |
imkwmoore@gmail.com |
Owner |
Burlington |
DesMoines |
Iowa |
Kevin Moore |
DeeAnn Howar |
Signed |
615 |
2023-02-28 08:15 |
Anonymous (not verified) |
94.188.207.224 |
River City Transport |
201 Lezlie Dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2023-02-28 |
Christopher Ryan Brewer |
chris@rivercitylogistics.net |
Peosta |
Dubuque County |
Iowa |
Brian Brewer |
Nicholas Lester |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chris Brewer |
chris@rivercitylogistics.net |
Owner |
Peosta |
Iowa |
United States |
Brian Brewer |
Nicholas Lester |
Signed |
617 |
2023-03-02 18:39 |
Anonymous (not verified) |
94.188.205.167 |
Fosters woodworking and design llc |
26498 g ave, adel ia 50003 |
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. |
2023-03-02 |
Nicholas Foster |
nick@fosterswooddesign.com |
Adel |
Dallas |
Iowa |
Tanya Foster |
Mike Merrick |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nicholas Foster |
nfoster1988@icloud.com |
Owner |
Adel |
Dallas |
Iowa |
Tanya foster |
Mike merrick |
Signed |
619 |
2023-03-06 09:02 |
Anonymous (not verified) |
94.188.207.229 |
Gaytan Framing LLC |
4745 NE 27th Ct Des Moines IA 50317 |
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. |
2023-03-06 |
Jose Gaytan |
jose1988.jg8@gmail.com |
Des Moines |
Iowa |
United States |
Carla Gaytan |
Eduardo Vazquez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jose Gaytan |
jose1988.jg8@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Carla Gaytan |
Eduardo Vazquez |
Signed |
620 |
2023-03-06 09:26 |
Anonymous (not verified) |
94.188.207.225 |
Monhec industrial construction llc |
616 sw 62 nd st desmoines iowa 50312 |
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. |
2023-03-06 |
Hector Montoya |
halexisjr@hotmail.com |
Desmoines |
Polk |
Iowa |
Adriana rojo |
Jeremy boeck |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Hector Montoya |
halexisjr@hotmail.com |
Owner |
Desmoines |
Polk |
Iowa |
Adriana rojo |
Jeremy boeck |
Signed |
623 |
2023-03-08 13:48 |
Anonymous (not verified) |
94.188.205.174 |
Jim & Laini's Trucking Inc |
11591 Rupp Hollow 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. |
2023-03-08 |
James Harry |
jltiowa@gmail.com |
DUBUQUE |
IA |
United States |
Christopher T Clarke |
Chris Clarke |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Harry |
jltiowa@gmail.com |
owner |
DUBUQUE |
IA |
United States |
Christopher T Clarke |
Chris Clarke |
Signed |
624 |
2023-03-08 13:50 |
Anonymous (not verified) |
94.188.205.177 |
Jim & Laini's Trucking Inc |
11591 Rupp Hollow 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. |
2023-03-08 |
Elaine Harry |
jltiowa@gmail.com |
DUBUQUE |
Iowa |
United States |
Christopher T Clarke |
Chris Clarke |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Harry |
jltiowa@gmail.com |
owner |
DUBUQUE |
IA |
United States |
Christopher T Clarke |
Chris Clarke |
Signed |
633 |
2023-03-22 14:36 |
Anonymous (not verified) |
94.188.205.175 |
Guardian Real Estate Inspection Services LLc |
2623 Shady Lane Dr Norwalk, IOWA 50211 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-22 |
Scott Edwards |
Scott@imperialia.com |
Norwalk |
Iowa |
IA |
Jesus San Elias |
Tim Mullin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott Edwards |
scott@imperialia.com |
Owner |
NORWALK |
IA |
United States |
Jesus San Elias |
Tim Mullin |
Signed |
634 |
2023-03-22 14:40 |
Anonymous (not verified) |
94.188.205.167 |
Guardian Real Estate Inspection Services LLc |
2623 Shady Lane Dr Norwalk, Iowa 50211 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-22 |
Joseph D Nelson |
scott@imperialia.com |
West Des Moines |
Polk |
Iowa |
Pedro Antonio |
Steve Flynn |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph Neslon |
Scott@imperialia.com |
Owner |
West Des Moines |
IA |
Iowa |
Steve Flynn |
Pedro Antonio |
Signed |
638 |
2023-03-25 13:19 |
Anonymous (not verified) |
94.188.207.227 |
Paradigm Group LLC |
960 Pelican 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. |
2023-03-13 |
Dalton Vest |
vestdalton@gmail.com |
State Center |
Marshal |
Iowa |
Andie Phillips |
Kade Steuhm |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ryan Shabino |
ryan@prdgmgroup.com |
Owner |
Polk City |
Polk |
Iowa |
Andie Phillips |
Kade Steuhm |
Signed |
640 |
2023-03-28 18:28 |
Anonymous (not verified) |
94.188.205.174 |
SM TILE DESIGN LLC |
670 Daybreak dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-28 |
Samir Mulalic |
smtiledesign@gmail.com |
Waukee |
Iowa |
United States |
Samir Mulalic |
Saneta Dzankovic |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Samir Mulalic |
smtiledesign@gmail.com |
Owner |
Waukee |
Iowa |
United States |
Samir Mulalic |
Saneta Dzankovic |
Signed |
649 |
2023-04-07 11:56 |
Anonymous (not verified) |
94.188.207.223 |
Wilcox Property Management Inc |
300 N. 3rd St, Carlisle, IA 50047 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-07 |
William Wilcox |
bill@advancedasi.com |
Carlisle |
Polk |
IA |
Gary J Meyers |
James R Simmons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William Wilcox |
bill@advancedasi.com |
Owner |
Carlisle |
Polk |
IA |
Gary J Meyers |
James R Simmons |
Signed |
652 |
2023-04-17 16:23 |
Anonymous (not verified) |
94.188.205.177 |
alternative sport enterprises llc |
506 6th st coralville IA 52241 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-17 |
nick carroll |
nick.carroll@mchsi.com |
Coralville |
IA |
United States |
Kaylyn Olson |
Jake Braman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
nick carroll |
nick.carroll@mchsi.com |
owner |
Coralville |
IA |
United States |
Kaylyn Olson |
Jake Braman |
Signed |
653 |
2023-04-17 16:37 |
Anonymous (not verified) |
94.188.205.166 |
alternative sport enterprises llc |
506 6th 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. |
2023-04-17 |
James Pearson |
jimpearson444@yahoo.com |
Savage |
scott |
MN |
Kaylyn Olson |
Jake Braman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
nick carroll |
nick.carroll@mchsi.com |
Owner |
Coralville |
IA |
United States |
Kaylyn Olson |
Jake Braman |
Signed |
655 |
2023-04-18 16:59 |
Anonymous (not verified) |
94.188.205.166 |
Next level tile and marble |
6918 NW 4th st Ankeny Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-18 |
Jason John Henry Schneider |
jjhschneider@gmail.com |
Ankeny |
Polk |
Iowa |
Mario Demarco |
Jennifer Schneider |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jason Schneider |
jjhschneider@gmail.com |
Owner |
Ankeny |
Polk |
Iowa |
Mario Demarco |
Jennifer Schneider |
Signed |
657 |
2023-04-20 11:33 |
Anonymous (not verified) |
94.188.205.177 |
Debra Higgins |
201 Cedar 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. |
2023-04-20 |
Debra Higgins |
diggs0519@icloud.com |
Slater |
IA |
United States |
Howard Higgins |
Howard Higgins |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Debra Higgins |
diggs0519@icloud.com |
owner |
Slater |
IA |
United States |
Howard Higgins |
Howard Higgins |
Signed |
658 |
2023-04-20 11:39 |
Anonymous (not verified) |
94.188.205.167 |
Old Pros Consulting Inc |
201 Cedar St Slater Iowa 50244 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-20 |
Debra Higgins |
diggs0519@icloud.com |
Slater |
IA |
United States |
Howard Higgins |
Howard Higgins |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Debra Higgins |
diggs0519@icloud.com |
owner |
Slater |
IA |
United States |
Howard Higgins |
Howard Higgins |
Signed |
659 |
2023-04-21 13:58 |
Anonymous (not verified) |
94.188.205.168 |
Streamline Plumbing LLC |
1513 Nw 8th St Grimes, IA 50111 |
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. |
2023-04-21 |
Benjamin Molloy |
slplumbing.llc@gmail.com |
Grimes |
IA |
United States |
Christine Darnell |
Steven Perona |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Benjamin Molloy |
slplumbing.llc@gmail.com |
owner |
Grimes |
IA |
United States |
Christine Darnell |
Steven Perona |
Signed |
660 |
2023-04-26 07:56 |
Anonymous (not verified) |
94.188.207.227 |
Darrin Hearn DBA GoodCauseMinis |
445 Onyx Ave Marion IA 52302 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-26 |
Darrin Hearn |
goodcauseminis@gmail.com |
Marion |
IA |
United States |
Darrin Hearn |
Darrin Hearn |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Darrin Hearn |
goodcauseminis@gmail.com |
owner |
Marion |
IA |
United States |
Darrin Hearn |
Darrin Hearn |
Signed |
661 |
2023-04-29 10:04 |
Anonymous (not verified) |
94.188.205.177 |
Planetary Tree Service |
166 Brovan blvd, evansdale, iowa 50707 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-29 |
Andrew Jon Collins |
thetreeguy2000@gmail.com |
Evansdale |
Black Hawk |
Iowa |
Jennifer Selleck |
Carolyn Inman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andrew Jon Collins |
thetreeguy2000@gmail.com |
Owner |
Evansdale |
Black hawk |
Iowa |
Jennifer renee selleck |
Carolyn kay Inman |
Signed |
670 |
2023-05-18 12:21 |
Anonymous (not verified) |
94.188.205.175 |
innovations General contractors |
1134 20th ave East Moline IL 61244 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-18 |
Juan Carlos |
innovationsGENC@gmail.com |
East Moline |
Rock Island |
Illinois |
Jacinto Perez Lopez |
Pionaolo Davalos |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
juan Carlos Soto Deanda |
InnovationsGENC@gmail.com |
owner |
East moline |
Rock Island |
illinois |
jacinto Perez Lopez |
Pianolo Davalos |
Signed |
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 |
677 |
2023-06-02 10:14 |
Anonymous (not verified) |
94.188.207.225 |
Diamond ridge roofing |
1842 glenwood circle, Des Moines, IA 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-02 |
Marianna Landeros |
landerosmary@gmail.com |
Des moines |
Polk |
IA |
Jessica newton |
Tom newton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Marianna landeros |
landerosmary@gmail.com |
Owner |
Des moines |
Polk |
IA |
Jessica newton |
Tom newton |
Signed |
681 |
2023-06-07 12:28 |
Anonymous (not verified) |
94.188.205.166 |
Staley Tile |
328 South 4th Avenue |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-07 |
Scott Wayne Staley |
staleyscott@yahoo.com |
Winterset |
Madison |
Iowa |
Michelle Rene Baker |
Mario DeMarco |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott Wayne Staley |
staleyscott@yahoo.com |
Owner |
Winterset |
Madison |
Iowa |
Michelle Rene Baker |
Mario DeMarco |
Signed |
685 |
2023-06-15 12:30 |
Anonymous (not verified) |
94.188.205.168 |
Des Moines Marble & Mantel Co. Inc. |
1507 Ohio Street Des Moines, IA 50314 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-15 |
Benjamin Campos Rojas |
caya05rojas@gmail.com |
Des Moines |
Polk county |
Iowa |
Erica Antonio Maya |
Ana Antonio Maya |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mario DeMarco |
sandyatdmmarble@aol.com |
Owner |
Des Moines |
Polk County |
Iowa |
Erica Antonio Maya |
Ana Antonio Maya |
Signed |
686 |
2023-06-15 21:36 |
Anonymous (not verified) |
94.188.207.229 |
Des Moines Marble & Mantel Co.Inc. |
1507 Ohio Street Des Moines, IA 50314 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-15 |
Ezequiel Campos Rojas |
Zequiel.11campos@gmail.com |
Des Moines |
POLK |
IOWA |
Daysi Campos Gaytan |
Rosalba Soto Hernandez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mario DeMarco |
sandyatdmmarble@aol.com |
Owner |
Des Moines |
Polk |
iowa |
Daysi Campos Gaytan |
Rosalba Soto Hernandez |
Signed |
687 |
2023-06-16 07:59 |
Anonymous (not verified) |
94.188.207.230 |
Benjamin Campos Rojas |
4024 52nd Street 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. |
2023-06-16 |
Benjamin Campos Rojas |
caya05rojas@gmail.com |
Des Moines |
Polk |
Iowa |
Erica Antonio Maya |
Ana Antonio Maya |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Benjamin Campos Rojas |
caya05rojas@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Erica Antonio Maya |
Ana Antonio Maya |
Signed |
688 |
2023-06-16 08:08 |
Anonymous (not verified) |
94.188.205.169 |
Ezequiel Campos Rojas |
2910 50th Street 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. |
2023-06-16 |
Ezequiel Campos Rojas |
Zequiel.11campos@gmail.com |
Des Moines |
Polk |
Iowa |
Daysi Campos Gaytan |
Rosalba Soto Hernandez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ezequiel Campos Rojas |
Zequiel.11campos@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Daysi Campos Gaytan |
Rosalba Soto Hernandez |
Signed |
689 |
2023-06-19 07:31 |
Anonymous (not verified) |
94.188.207.228 |
Nenger Argueta |
1317 5th Avenue Des Moines, Iowa 50314 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-19 |
Nenger Argueta |
arguetanenger30@gmail.com |
Des Moines |
Polk |
Iowa |
Gelbar Argueta |
Grace Argueta |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nenger Argueta |
arguetanenger30@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Gelbar Argueta |
Grace Argueta |
Signed |
690 |
2023-06-19 07:38 |
Anonymous (not verified) |
94.188.205.177 |
Jorge L. Ibarra |
2723 Easton Bld. |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-19 |
Jorge L. Ibarra |
jorgeluisibarra81@gmail.com |
Des Moines |
Polk |
Iowa |
Veronica Carreras |
Leonardo Ibarra |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jorge L. Ibarra |
jorgeluisibarra81@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Veronica Carreras |
Leonardo Ibarra |
Signed |
691 |
2023-06-19 07:43 |
Anonymous (not verified) |
94.188.207.228 |
Saul Carreras-Barron |
2529 E Walnut Street Des Moines, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-19 |
Saul Carreras-Barron |
saulcarreas@gmail.com |
Des Moines |
Polk |
Iowa |
Jesus Carreras |
Maria Barron |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Saul Carreras-Barron |
saulcarreas@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Jesus Carreras |
Maria Barron |
Signed |
692 |
2023-06-19 08:00 |
Anonymous (not verified) |
94.188.207.224 |
Mr chipper llc |
1606 carrie ave 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. |
2023-06-19 |
Nicholas Earles |
mrchipper2020@gmail.com |
Des Moines |
Iowa |
United States |
Nicholas belger |
Melanie earles |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nicholas Earles |
mrchipper2020@gmail.com |
Owner |
Des Moines |
Iowa |
United States |
Nicholas belger |
Melanie earles |
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 |
701 |
2023-06-22 15:06 |
Anonymous (not verified) |
94.188.205.166 |
Des Moines Contractors |
833 Buchanan st Des Moines ia 50316 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-22 |
Maison Wayne Miller |
DesMoinesContractors@gmail.com |
Des Moines |
Polk |
Iowa |
Kent Sorenson |
Krista Sheriff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Maison Wayne Miller |
DesMoinescontractors@gmail.com |
Owner |
Des moines |
IA |
United States |
Kent Sorenson |
Krista Sheriff |
Signed |
702 |
2023-06-27 07:04 |
Anonymous (not verified) |
94.188.207.230 |
Dancom Inc |
1001 Office Park Rd, West Des Moines, IA 50265 |
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. |
2023-06-26 |
Daniel Otundo |
daniel@dancoms.com |
Waukee |
Polk |
IA |
Joe Meyers |
Robert Simmons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Otundo |
daniel@dancoms.com |
Owner |
Waukee |
Polk |
IA |
Robert Simmons |
Joe Meyers |
Signed |
703 |
2023-06-27 07:05 |
Anonymous (not verified) |
94.188.207.229 |
Dancom Inc |
1001 Office Park Rd, West Des Moines, IA 50265 |
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. |
2023-06-26 |
Calvin Otundo |
calvin@dancoms.com |
Waukee |
Polk |
IA |
Joe Meyers |
Robert Simmons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Calvin Otundo |
calvin@dancoms.com |
Owner |
Waukee |
Polk |
IA |
Robert Simmons |
Joe Meyers |
Signed |
705 |
2023-07-06 14:24 |
Anonymous (not verified) |
94.188.205.167 |
Portwood H3D Consulting |
1109 295th Street, Oxford Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-07-06 |
Brian Portwood |
portwoodh3dconsulting@gmail.com |
Oxford |
Johnson |
Iowa |
Bob Herring |
Chelsey Atkinson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brian Portwood |
portwoodh3dconsulting@gmail.com |
owner |
Oxford |
Johnson |
Iowa |
Bob Herring |
Chelsey Atkinson |
Signed |
706 |
2023-07-06 17:45 |
Anonymous (not verified) |
94.188.207.230 |
Gaytán Framing |
5303 Brook landing cir Des Moines, Iowa 50317 |
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. |
2023-07-06 |
Jose Gaytán Ruiz |
jose1988.jg8@gmail.com |
Des moines |
Polk |
Iowa |
Pedro zelaya |
Yeraldi nabor |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jose Gaytán Ruiz |
jose1988.jg8@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Pedro zelaya |
Yeraldi Nabor |
Signed |
707 |
2023-07-10 12:50 |
Anonymous (not verified) |
94.188.207.228 |
Gaytán Framing |
5303 Brook Landing Cir Des Moines Ia 50317 |
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. |
2023-07-10 |
Jose Gaytán Ruiz |
pedro.j.zelaya@gmail.com |
Des moines |
Polk |
Iowa |
Pedro zelaya |
Yeraldi Nabor |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jose Gaytán Ruiz |
pedro.j.zelaya@gmail.com |
Owner |
Des moines |
Polk |
Iowa |
Pedro Zelaya |
Yeraldi nabor |
Signed |
713 |
2023-07-25 12:26 |
Anonymous (not verified) |
94.188.205.174 |
HT&T Drywall |
479 old lincoln hwy Mechanicsville Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-07-25 |
Tracy Spray |
tspray9@hotmail.com |
Mechanicsville |
Cedar |
Iowa |
Dillon Williams |
Leighton Raplinger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tracy Spray |
tspray9@hotmail.com |
Owner |
Mechanicsville |
Cedar |
Iowa |
Dillon Williams |
Leighton Raplinger |
Signed |
714 |
2023-07-25 16:16 |
Anonymous (not verified) |
94.188.207.224 |
Midwest Systems |
2877 130th St Aurora, Ia 50607 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-07-25 |
Matt Griswold |
midwestsystems@live.com |
Aurora |
IA |
United States |
Creatleigh Griswold |
Carslyn Griswold |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Matt Griswold |
midwestsystems@live.com |
Owner |
Aurora |
IA |
United States |
Creatleigh Griswold |
Carslyn Griswold |
Signed |
718 |
2023-07-27 08:43 |
Anonymous (not verified) |
94.188.207.225 |
HT&T Drywall |
479 Old Lincoln Hwy |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-07-27 |
Tracy Spray |
tspray9@hotmail.com |
Mechanicsville |
Cedar |
Iowa |
Dillon Williams |
Leighton Raplinger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tracy Spray |
tspray9@hotmail.com |
Owner |
Mechanicsville |
Cedar |
Iowa |
Dillon Williams |
Leighton Raplinger |
Signed |
722 |
2023-08-01 11:55 |
Anonymous (not verified) |
94.188.207.229 |
SM TILE DESIGN LLC |
670 Daybreak dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-01 |
Samir Mulalic |
smtiledesign@gmail.com |
Waukee |
Iowa |
United States |
Samir Mulalic |
Saneta Dzankovic |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Samir Mulalic |
smtiledesign@gmail.com |
Owner |
Waukee |
Iowa |
United States |
Samir Mulalic |
Saneta Dzankovic |
Signed |
723 |
2023-08-01 15:37 |
Anonymous (not verified) |
94.188.205.169 |
Flow Media, Inc |
1710 Wenig Rd NE |
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. |
2023-08-01 |
Courtney Tabelisma Ball |
courtney@flowmedia.com |
Cedar Rapids |
IA |
United States |
Hannah Jane White |
Gregory Michael White |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Courtney Tabelisma Ball |
courtney@flowmedia.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Sonya Catherine Geenen |
Gregory Michael White |
Signed |
724 |
2023-08-02 16:09 |
Anonymous (not verified) |
94.188.207.223 |
Magnussen Bros Inc |
1945 560th Street, Newell, IA 50568 |
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. |
2023-08-02 |
Duane Magnussen |
dcmag@ncn.net |
Newell |
Buena Vista |
Iowa |
Jared Brashears |
Katie Gunkelman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Duane Magnussen |
ncmag@ncn.net |
Owner |
Newell |
Buena Vista |
IA |
Jared Brashears |
Katie Gunkelman |
Signed |
729 |
2023-08-04 07:39 |
Anonymous (not verified) |
94.188.207.228 |
Barrel Head Winery Inc |
9995 Laudeville Road, Dubuque, IA 52003 |
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. |
2023-08-03 |
Aaron Fuhreck |
sales@barrelheadiowa.com |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Aaron Fuhreck |
sales@barrelheadiowa.com |
Owner |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Derrick Parsons |
Signed |
730 |
2023-08-04 07:42 |
Anonymous (not verified) |
94.188.207.225 |
Barrel Head Winery Inc |
9995 Laudeville Road, Dubuque, IA 52003 |
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. |
2023-08-03 |
Jodie Fuhreck |
sales@barrelheadiowa.com |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jodie Fuhreck |
sales@barrelheadiowa.com |
Owner |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Derrick Parsons |
Signed |
731 |
2023-08-04 09:43 |
Anonymous (not verified) |
94.188.207.229 |
Hopp's Computers & More |
855 S. Page St., Nauvoo, IL 62354 |
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. |
2023-08-04 |
James Hopp |
tech@hoppcomputers.com |
Nauvoo |
Hancock |
Illinois |
Carol McGhghy |
Ana LeVesque |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Hopp |
tech@hoppcomputers.com |
Owner |
Nauvoo |
Hancock |
Illinois |
Carol McGhghy |
Ana LeVesque |
Signed |