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Rejection of Workers' Compensation or Employers' Liability Coverage

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# Submitted User IP address Name of Corporation: Address of Corporation Home Office: Statement 1 Agreement: Statement 2 Agreement: Statement 3 Agreement: Statement Agreement: Check Either Alternative (1) or (2): Date: Full Name of Individual: Email: City of Residence: County of Residence: State of Residence: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Agreement: Alternative Selection: Full Name of Authorized Agent: Email of Authorized Agent: Relationship to Corporation of Authorized Agent: City of Residence: County of Residence: State: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Indication:
443 2022-04-11 13:15 Anonymous (not verified) 75.162.175.12 Castro construction LLC 1712 carpenter av desmoines 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. 2022-04-11 Carlos Alberto castro Alcántara castrodvxhd@gmail.com Estados Unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe padilla bonilla Signed (1) The corporation rejects the employers’ liability coverage. Carlos Alberto castro Alcántara castrodvxhd@gmail.com Owner Estados unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe Padilla Bonilla 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
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
402 2022-02-09 09:46 Anonymous (not verified) 69.57.33.202 Toby K's Hideaway Inc. dba Toby K's Hideaway 1723 Mamie Eisenhower Ave, Boone IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-09 Toby Kruse samanthapeck@boehmins.com Boone Boone Iowa Samantha Peck Hans Boehm Signed (1) The corporation rejects the employers’ liability coverage. Toby Kruse samanthapeck@boehmins.com Owner Boone Boone Iowa Samantha Peck Hans Boehm Signed
328 2021-09-08 08:31 Anonymous (not verified) 97.125.157.23 Dan Petersen Construction 1725 S 14th St, Polk City, IA 50026 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 Daniel Petersen danpetersenconstruction@gmail.com Polk City Polk County Iowa Jim McMurray Erik Gramenz Signed (1) The corporation rejects the employers’ liability coverage. Daniel Petersen danpetersenconstruction@gmail.com Owner Polk City Polk Iowa Jim McMurray Erik Gramenz Signed
139 2020-11-24 15:45 Anonymous (not verified) 174.219.2.33 Dan Petersen Construction LLC 1725 South 14th St, Polk City, IA 50226 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2019-11-24 Daniel Petersen danpetersenconstruction@gmail.com Polk City Polk Iowa Erik Gramenz Jim McMurray Signed (1) The corporation rejects the employers’ liability coverage. Daniel Petersen danpetersenconstruction@gmail.com Owner Polk City Polk Iowa Erik Gramenz Jim McMurray Signed
608 2023-02-22 16:15 Anonymous (not verified) 94.188.207.225 Unity Global Inc 1779 Shooting Star Ave, Fairfield, IA 52556 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-04 Hagen Rainbow unityglobalinc@protonmail.com Fairfield Jefferson Iowa Peter Defreitas Barbara Rainbow Signed (1) The corporation rejects the employers’ liability coverage. Hagen Rainbow unityglobalinc@protonmail.com President Fairfield Jefferson Iowa Peter Defreitas Barbara Rainbow 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
985 2024-05-13 17:15 Anonymous (not verified) 94.188.207.225 Rail and Road Equipment Co 1797 G50 HWY. St. Charles, IA. 50240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-13 Jeffrey Pontier railandroad@myomnotel.com St Charles Warren IA Abbi Goering Travis Allen Signed (1) The corporation rejects the employers’ liability coverage. Jeffrey Pontier railandroad@myomnitel.com President St Charles Warren IA Abbi Goering Travis Allen Signed
986 2024-05-13 17:26 Anonymous (not verified) 94.188.207.229 Rail and Road Equipment Co 1797 G50 HWY. St. Charles, IA. 50240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-13 Ranae Pontier railandroad@myomnitel.com St Charles Warren IA Abbi Goering Travis Allen Signed (1) The corporation rejects the employers’ liability coverage. Ranae Pontier railandroad@myomnitel.com Vice President St Charles Warren IA Abbi Goering Travis Allen Signed
470 2022-05-12 14:28 Anonymous (not verified) 173.184.134.123 Bryce Hoffert LLC 1802 Lake Street Emmetsburg Iowa 50536 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. 2022-05-12 Bryce C Hoffert brycehoffertllc@gmail.com Emmetsburg Pala Alto Iowa Ray Hoffert Shelbie Hurdle Signed (1) The corporation rejects the employers’ liability coverage. Bryce Hoffert brycehoffertllc@gmail.com member Emmetsburg Palo Alto Iowa Ray Hoffert Shelbie Hurdle Signed
955 2024-04-11 10:31 Anonymous (not verified) 94.188.207.228 Calvillo & Son Construction 1802 mondamin ave 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. 2024-04-11 Gerardo Calvillo joedhsanchez@icloud.com Des Moines Polk Iowa Agustín Téllez Aurora Maciel Colin Signed (1) The corporation rejects the employers’ liability coverage. Gerardo Calvillo joedhsanchez@icloud.com Owner Des Moines Polk Iowa Agustín Téllez Aurora Maciel Colin Signed
957 2024-04-15 10:15 Anonymous (not verified) 94.188.207.226 Calvillo & Son Construction 1802 Mondamin Ave, 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. (2) I decline to reject the employer’s liability coverage. 2024-04-15 Gerardo Calvillo Joedhsanchez@icloud.com Des Moines Polk Iowa Agustín Téllez Aurora Maciel Colin Signed (2) The corporation declines to reject the employers’ liability coverage. Gerardo Calvillo Joedhsanchez@icloud.com Owner Des Moines Polk Iowa Agustín Téllez Aurora Maciel Colin Signed
378 2022-01-03 15:16 Anonymous (not verified) 217.180.230.157 True360, Inc. 1805 Collaboration Place, Suite 1300, Ames, Iowa 50010 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-03 Christopher James chris@true-360.com Ames Iowa United States Jesse Kisker Cody Kapka Signed (1) The corporation rejects the employers’ liability coverage. Christopher James chris@true-360.com President and Chief Executive Officer Ames Iowa United States Jesse Kisker Cody Kapka Signed
125 2020-10-26 16:33 Anonymous (not verified) 162.253.44.212 Gutter Filter Specialists Inc 1805 Red Fox Way 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. 2020-10-26 Richard L Mellor rickmellor88@gmail.com Marion Linn IA Katie Luehrsmann Melissa Lown Signed (1) The corporation rejects the employers’ liability coverage. Richard L Mellor rickmellor88@gmail.com President Marion Linn IA Katie Luehrsmann Melissa Lown Signed
521 2022-07-25 15:33 Anonymous (not verified) 199.66.14.149 ROSENBERGER ENTERPRISES, INC. 1813 N 7th St INDIANOLA, IA 50125 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-25 Diane Rosenberger diane@katanainc.com Indianola IA United States SPRING CRUBAUGH BRADY FRY Signed (2) The corporation declines to reject the employers’ liability coverage. Diane Rosenberger diane@katanainc.com Owner Indianola IA United States SPRING CRUBAUGH BRADY FRY Signed
694 2023-06-20 13:25 Anonymous (not verified) 94.188.207.229 Canvas Products Co. 182 Main Street Dubuque, Iowa 52001 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-20 Frank Salwolke frank@dbqcanvas.com Dubuque IA Iowa Ashley A. Trowbridge Taylor J. Trowbridge Signed (1) The corporation rejects the employers’ liability coverage. frank salwolke frank@dbqcanvas.com President DUBUQUE IA Iowa Ashley A. Trowbridge Taylor J. Trowbridge Signed
695 2023-06-20 13:27 Anonymous (not verified) 94.188.207.227 Canvas Products Co. 182 Main Street Dubuque, Iowa 52001 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-20 Mary A.Salwolke maryann@dbqcanvas.com Dubuque IA Iowa Ashley A. Trowbridge Taylor J. Trowbridge Signed (1) The corporation rejects the employers’ liability coverage. Frank J. Salwolke frank@dbqcanvas.com President Dubuque Ia Iowa Ashley A. Trowbridge Taylor J. Trowbridge Signed
696 2023-06-20 13:30 Anonymous (not verified) 94.188.207.226 Canvas Products Co. 182 Main Street Dubuque, Iowa 52001 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-20 Jacob I. Salwolke jake@dbqcanvas.com sherrill IA Iowa Ashley A. Trowbridge Taylor J. Trowbridge Signed (1) The corporation rejects the employers’ liability coverage. Frank J. Salwolke frank@dbqcanvas.com President dubuque IA Iowa Ashley A. Trowbridge Taylor J. Trowbridge Signed
937 2024-03-30 17:30 Anonymous (not verified) 94.188.205.167 AR Drilling LLC 1821 Roebling Rd, 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. 2024-03-30 Luis Serrano serranoluis7667@gmail.com Adel Dallas IA Kelly green Thomas Green Signed (1) The corporation rejects the employers’ liability coverage. Luis Serrano serranoluis7667@gmail.com Owner Adel Dallas IA Kelly Green Thomas Green Signed
588 2023-01-13 10:49 Anonymous (not verified) 173.17.248.155 Cheri's 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. 2023-01-13 Cheryl Martinez cheri6876@yahoo.com Des Moines Polk Iowa Jessica L Newton Thomas C Newton Signed (1) The corporation rejects the employers’ liability coverage. Cheryl Martinez cheri6876@yahoo.com Owner Des Moines Polk Iowa Jessica L Newton Thomas C Newton 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
98 2020-07-11 16:34 Anonymous (not verified) 50.83.184.81 Paradigm Construction LLC 1847 nw 90th st Clive, IA 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-07-06 Jonathon Richard Curtis joncurtis15@gmail.com Des Moines Polk IA Yolanda Curtis Susan Brooker Signed (2) The corporation declines to reject the employers’ liability coverage. Ryan Shabino ryan@prdgmconstruction.com Contractor Clive Polk IA Yolanda Curtis Susan Brooker Signed
371 2021-12-09 11:03 Anonymous (not verified) 216.81.176.153 Concentric International Inc. 1901 Bell Ave Ste 18, Des Moines, IA 50315-1067 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. 2021-12-09 Tracey Ball tball@ruan.com Urbandale IA United States Jackie Walker Craig Gesme Signed (1) The corporation rejects the employers’ liability coverage. Tracey Ball tball@ruan.com Treasurer Urbandale IA United States Jackie Walker Craig Gesme Signed
857 2024-01-17 16:04 Anonymous (not verified) 94.188.205.167 GA Drywall LLC 1906 West State Street Marshalltown Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-17 Oscar Vazquez LOPEZ gadrywall7@icloud.com Marshalltown Marshall Iowa Ana Ibarra Ana Lopez Signed (1) The corporation rejects the employers’ liability coverage. Oscar Vazquez Lopez oscarlopez177@icloud.com Owner Marshalltown Marshall Iowa Ana Ibarra Ana Lopez Signed
980 2024-05-10 14:51 Anonymous (not verified) 94.188.205.176 Access Door Automation 19068 Mynster Springs 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. 2024-05-10 Marshall Miller millermarshallt@outlook.com council bluffs Iowa United States Kylee Miller Ivy Miller Signed (1) The corporation rejects the employers’ liability coverage. Marshall Miller millermarshallt@outlook.com owner council bluffs Iowa United States Kylee Miller Ivy Miller Signed
57 2020-04-10 11:14 Anonymous (not verified) 136.34.78.83 KALONA SALES BARN, INC. 191 9TH STREET; KALONA, IA 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. 2020-04-07 DEVIN MULLET LMULLET@KALONASALESBARN.COM KALONA WASHINGTON IOWA ALANA MULLET ROCHELLE MULLET Signed (1) The corporation rejects the employers’ liability coverage. DEVIN MULLET LMULLET@KALONASALESBARN.COM OWNER KALONA WASHINGTON IOWA ALANA MULLET ROCHELLE MULLET Signed
915 2024-03-08 13:24 Anonymous (not verified) 94.188.205.174 One Call Exterior LLC 1918 9th St Des Moines 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. 2024-03-08 Nancy G Lopez onecallexteriors@gmail.com Des Moines Polk IA Monica Martinez Noe Ordaz Signed (1) The corporation rejects the employers’ liability coverage. Nancy G Lopez onecallexteriors@gmail.com Self Ames Story IA Monica Martinez Noe Ordaz Signed
119 2020-09-28 10:43 Anonymous (not verified) 174.213.149.6 Ddp construction 1923 63rd st, des moines ,ia 50322 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-28 Dustin a perry perrythedustin@gmail.com Urbandale Polk Iowa Lucas jackson Cody roth Signed (1) The corporation rejects the employers’ liability coverage. Smith Kenyon insurance smithkenyon@yahoo.com Agent Urbandale Polk Ia Lucas jackson Cody roth Signed
518 2022-07-21 10:58 Anonymous (not verified) 75.162.31.164 Bengard Roofing LLC 1927 Wethersfield Dr, Norwalk, IA 50211 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-21 Brandon Bengard bj@bengardroofing.com Norwalk Warren IA Rebecca Bengard Juhl Bengard Signed (1) The corporation rejects the employers’ liability coverage. Brandon Bengard bj@bengardroofing.com Owner Norwalk Warren IA Becky Bengard Juhl Bengard Signed
373 2021-12-10 14:49 Anonymous (not verified) 173.29.69.100 CARSTENS FLOOR COVERINGS LLC 19276 250TH STREET ELDRIDGE, IA 52748 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. 2021-12-10 MATHEW CARSTENS MCARSTENS@NETINS.NET ELDRIDGE SCOTT IA TONY BURKHART BETH LEMONS Signed (1) The corporation rejects the employers’ liability coverage. MATTHEW CARSTENS MCARSTENS@NETINS.NET PRESIDENT ELDRIDGE SCOTT IA TONY BURKHART BETH LEMONS Signed
880 2024-02-04 18:45 Anonymous (not verified) 94.188.205.176 One Call Exteriors 1928 9th St 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. 2024-02-04 Nancy López onecallexteriors@gmail.com Des Moines Polk IA Noé Ordaz Angie Florian Signed (1) The corporation rejects the employers’ liability coverage. Nancy López onecallexteriors@gmail.com Owner Des Moines Polk IA Noé Ordaz Angie Florian Signed
888 2024-02-12 12:35 Anonymous (not verified) 94.188.205.167 Standard Builders DBA Midwest Seamless 1930 e army post rd., Des Moines IA I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-12 Andy and Axell Construction LLC bradymaher9@gmail.com Des Moines Polk IA Michael Maher Brady Maher Signed (1) The corporation rejects the employers’ liability coverage. michael maher mikemaher@midwestseamless.com Owner/President PRAIRIE CITY Jasper IA Brady Maher fernando perez Signed
460 2022-05-02 10:00 Anonymous (not verified) 73.9.3.194 ERLIN AVILA INC 1940 N GREEN LN APT 2A PALATINE IL 60074 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-02 ERLIN AVILA INC dianalcandelaria@aol.com PALATINE COOK IL DIANA CANCELARIA DALILA VILLEGAS Signed (1) The corporation rejects the employers’ liability coverage. ERLIN AVILA TORREZ dianalcandelaria@aol.com PRESIDENT PALATINE Illinois United States Diana L Candelaria DALILA VILLEGAS 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
84 2020-06-01 16:31 Anonymous (not verified) 173.29.126.110 TruthPoint Media LLC 1945 Andrews Drive, Pleasant Hill, IA 50327 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-06-01 Robert Lee Moore robb@truthpointmedia.com Pleasant Hill Polk Iowa Self, Sole Proprietor and LLC Member, TruthPoint Media LLC Self, Sole Proprietor and LLC Member, TruthPoint Media LLC Signed (1) The corporation rejects the employers’ liability coverage. Robert L Moore robb@truthpointmedia.com Self Pleasant Hill Polk Iowa Self, Sole Proprietor and LLC Member, TruthPoint Media LLC Self, Sole Proprietor and LLC Member, TruthPoint Media LLC Signed
725 2023-08-02 17:25 Anonymous (not verified) 94.188.207.225 Furever Friends Rescue of Appanoose, Inc 19507 Hwy 2, Centerville, Iowa 52544 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 Dustin Cain Bozwell dcbozwell@gmail.com Centerville Appanoose Iowa Kimberly Stonehouse Jennifer Appler Signed (1) The corporation rejects the employers’ liability coverage. Dustin Bozwell dcbozwell@gmail.com President Centerville Appanoose Iowa Kimberly Stonehouse Jennifer Appler Signed
726 2023-08-02 17:30 Anonymous (not verified) 94.188.205.169 Furever Friends of Appanoose, Inc 19507 Hwy 2, Centerville, Iowa 52544 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 Clint Raymond Housh clinthoush@lockridgeinc.com Centerville Appanoose Iowa Brian Seeman Drew Power Signed (1) The corporation rejects the employers’ liability coverage. Clint Housh clinthoush@lockridgeinc.com Vice President Centerville Appanoose Iowa Brian Seeman Drew Power Signed
727 2023-08-02 18:25 Anonymous (not verified) 94.188.205.176 Furever Friends Rescue of Appanoose, Inc 19507 Hwy 2, Centerville, Iowa 52544 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 Krystal Fowler krystalfowler@gmail.com Cincinnati Appanoose Iowa Jennifer Appler Kimberly Stonehouse Signed (1) The corporation rejects the employers’ liability coverage. Krystal Fowler krystalfowler@gmail.com Treasurer Cincinnati Appanoose Iowa Jennifer Appler Kim Stonehouse Signed
408 2022-02-18 11:30 Anonymous (not verified) 173.31.148.43 PACKEBUSH SPRINKLER SERVICE INC 1960 170TH AVE 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. 2022-02-09 ROSS PACKEBUSH RKPACKEBUSH@GMAIL.COM MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The corporation rejects the employers’ liability coverage. ROSS PACKEBUSH joel@walkerinsuranceia.com PRESIDENT MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
409 2022-02-18 11:32 Anonymous (not verified) 173.31.148.43 PACKEBUSH SPRINKLER SERVICE INC 1960 170TH AVE 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. 2022-02-09 KARA PACKEBUSH RKPACKEBUSH@GMAIL.COM MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The corporation rejects the employers’ liability coverage. KARA PACKEBUSH JOEL@WALKERINSURANCEIA.COM VICE PRESIDENT MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
816 2023-11-15 15:22 Anonymous (not verified) 94.188.205.166 MO VALLEY TACO INC 1971 LINCOLN HWY MISSOURI VALLEY IA 51555 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. 2023-11-01 MARTIN ALVAREZ abelardosmexicanfresh7@gmail.com MISSOURI VALLEY HARRISON IA GONZALO MUNOZ SILVIA CHAVEZ Signed (1) The corporation rejects the employers’ liability coverage. MARTIN ALVAREZ abelardosmexicanfresh7@gmail.com OWNER MISSOURI VALLEY HARRISON IA GONZALO MUNOZ SILVIA CHAVEZ Signed
817 2023-11-15 15:25 Anonymous (not verified) 94.188.205.175 MO VALLEY TACO INC 1971 LINCOLN HWY MISSOURI VALLEY IA 51555 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. 2023-11-01 REBECCA ALVAREZ abelardosmexicanfresh7@gmail.com MISSOURI VALLEY HARRISON IA GONZALO MUNOZ SILVIA CHAVEZ Signed (1) The corporation rejects the employers’ liability coverage. REBECCA ALVAREZ abelardosmexicanfresh7@gmail.com OWNER MISSOURI VALLEY HARRISON IA GONZALO MUNOZ SILVIA CHAVEZ 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
870 2024-01-26 07:57 Anonymous (not verified) 94.188.207.228 Kodiak Group Security LLC 1978 NW 92nd CT STE 2 Clive, Iowa 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-23 Howard Alton Johnston Jr howard@kodiakgroup.org Stuart Adair IA Joseph Crawford Howard Williams Signed (1) The corporation rejects the employers’ liability coverage. Howard Alton Johnston Jr howard@kodiakgroup.org Owner Stuart Adair Iowa Jospeh Crawford Howard Williams Signed
151 2021-01-01 11:26 Anonymous (not verified) 75.162.130.160 The Product Boss LLC 20 Mountain Way, West Orange, NJ 07052 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. 2021-01-01 Minna Khounlo-Sithep minna@theproductboss.com Ankeny IA IA Nalinh Sithep Suzzan Khounlo Signed (1) The corporation rejects the employers’ liability coverage. Minna Khounlo-Sithep minnaks@gmail.com Co-Owner Ankeny IA IA Nalinh Sithep Suzzan Khounlo Signed
227 2021-04-02 09:58 Anonymous (not verified) 207.177.7.191 GOETTSCH DISPATCH INC 200 MAIN ST GALVA, IA 51020 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. 2021-03-15 ANDREW GOETTSCH andygoettsch@gmail.com Galva Ida Iowa Kristy Dewey Terri Ullrich Signed (1) The corporation rejects the employers’ liability coverage. Andrew Goettsch andygoettsch@gmail.com President Galva Ida Iowa Kristy Dewey Terri Ullrich Signed
849 2024-01-10 10:47 Anonymous (not verified) 94.188.205.166 RedZone Football Academy LLC 2000 James St. Suite 205, 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. 2024-01-10 Tyler James Blum blum.tyler@gmail.com Oxford Johnson Iowa Cole Davis Trevor Bollers Signed (1) The corporation rejects the employers’ liability coverage. Tyler Blum redzonefbacademy@gmail.com same person, single member LLC/corp Oxford Johnson Iowa Cole Davis Trevor Bollers 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