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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:
180 2021-02-16 18:05 Anonymous (not verified) 216.248.123.206 Outer Edge Screen Printing 2449 68th Street Van Horne, Iowa 52346 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-02-16 Kimberly Sue Kline outedgekim@gmail.com Van Horne IA United States Amber Lynn Valentine Kelsea Marie Kline Signed (1) The corporation rejects the employers’ liability coverage. Outer Edge Screen Printing Co outedgekim@gmail.com Spouse Van Horne IA United States Amber Lynn Valentine Kelsea Marie Kline Signed
526 2022-08-17 11:16 Anonymous (not verified) 173.27.233.86 Bradens Roofing and Construction Llc 2450 Hart Avenue I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-08-17 Arsenio Vargas Velazquez avargas409@gmail.com Des Moines polk Iowa Julissa Dionicio Jennifer Dionicio Signed (1) The corporation rejects the employers’ liability coverage. Arsenio Vargas Velazquez avargas409@gmail.com owner Des Moines Polk Iowa Julissa Dionicio Jennifer Dionicio Signed
584 2022-12-09 11:34 Anonymous (not verified) 74.84.79.78 Luis Avila Zermeno 2457 E Kenyon Ave. Des Moines, IA 50320 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-01 Luis Avila Zermeno propainters-17@icloud.com Des Moines Polk Iowa Fatima Mendoza William Kirk Signed (1) The corporation rejects the employers’ liability coverage. Luis Avila Zermeno propainters-17@icloud.com Owner Des Moines Polk IA Fatima Mendoza William Kirk Signed
439 2022-03-29 19:23 Anonymous (not verified) 173.215.72.139 Vinton Enterprises LLC 24704 Isbell Lane, Glenwood, IA 51534 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-29 Holly Vinton vintonfive@hotmail.com Glenwood Mills Iowa David Pratt Chad MIller Signed (1) The corporation rejects the employers’ liability coverage. Holly Vinton vintonfive@hotmail.com owner Glenwood Mills Iowa David Pratt Chad Miller Signed
138 2020-11-24 14:11 Anonymous (not verified) 173.215.17.41 Dohrmann Enterprises, Inc 2478 260th Ave. DeWitt, Iowa 52742 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-11-24 Joel Dohrmann dohrmannpnh@gmail.com DE WITT Clinton IA Susanne Owen Daron Oberbroecking Signed (1) The corporation rejects the employers’ liability coverage. Susanne Owen sowen@ohnward.com none Camanche Clinton Iowa Joel Dohrmann Daron Oberbroecking Signed
275 2021-06-15 13:23 Anonymous (not verified) 172.98.131.84 JAVIER CONSTRUCTION INC 2503 Canyon St SW Cedar Rapids, IA 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-06-15 Javier Adana Javierconstruction88@gmail.com CEDAR RAPIDS LINN IOWA JASON SCHICK LADONNA SCHICK Signed (2) The corporation declines to reject the employers’ liability coverage. JASON SCHICK JASONSCHICK@NEIGHBORINSURANCE.COM INSURANCE AGENT CEDAR RAPIDS LINN IOWA JASON SCHICK LADONNA SCHICK Signed
289 2021-07-22 17:47 Anonymous (not verified) 172.58.83.5 Javier Construction INC 2503 canyon st sw Cedar Rapids,iowa 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-07-22 Javier Aldana Fuentes Javierconstruction88@gmail.com Cedar Rapids Linn Iowa DaZsa Aldana Donya Fleetwood Signed (1) The corporation rejects the employers’ liability coverage. Javier Aldana Fuentes Javierconstruction88@gmail.com owner Cedar Rapids LInn Iowa DaZsa Aldana Donya Fleetwood Signed
525 2022-08-11 19:30 Anonymous (not verified) 216.51.251.59 Ethan pliner trucking 2510 Kansas ave fort dodge Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-08-11 Ethan William pliner pliner15@hotmail.com Fort dodge iowa Webster Iowa Trey Kent Lawrence Aubrey Mae Holtorf Signed (1) The corporation rejects the employers’ liability coverage. Ethan pliner pliner15@hotmail.com Owner Fort Dodge Webster Iowa Trey Kent Lawrence Aubrey Mae Holtorf Signed
627 2023-03-17 06:48 Anonymous (not verified) 94.188.207.229 Hearing Health Care, LLC 2519 South 16th Street Council Bluffs, IA 51501 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. 2023-03-17 Melissa Ann Knoell melissaknoell@yahoo.com Council Bluffs Pottowattomi Iowa Bruce Carol Johnk Marcelyn Maureen Johnk Signed (1) The corporation rejects the employers’ liability coverage. Melissa Ann Knoell melissaknoell@yahoo.com Self Council Bluffs Pottawattomi Iowa Bruce Carol Johnk Marcelyn Maureen Johnk Signed
981 2024-05-10 15:31 Anonymous (not verified) 94.188.205.168 Jacob Thompson DBA Jake Thompson Trucking 2524 Delta Ave, Bridgewater, IA 50837 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 Jake Thompson jakethompsontrucking@yahoo.com Bridgewater Adair Iowa Daniela Scacchi Jeff Thompson Signed (1) The corporation rejects the employers’ liability coverage. Jake Thompson jakethompsontrucking@yahoo.com Self Bridgerwater Adair IA Daniela Scacchi Jeff Thompson Signed
600 2023-02-16 16:06 Anonymous (not verified) 94.188.207.225 Friday After Work LLC 2526 Rainbow Drive, Cedar Falls, IA 50613 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-01 Joshua Carder josh.cve@gmail.com Cedar Falls Black Hawk Iowa Brady Huls Tyler Reynolds Signed (1) The corporation rejects the employers’ liability coverage. Brent Dunlop fawconstruction.ia@gmail.com Owner Cedar Falls Black Hawk Iowa Brady Huls Tyler Reynolds Signed
601 2023-02-16 16:08 Anonymous (not verified) 94.188.207.223 Friday After Work LLC 2526 Rainbow Drive, Cedar Falls, IA 50613 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-01 Tyler Reynolds tyler.cve@gmail.com Cedar Falls Black Hawk Iowa Brady Huls Joshua Carder Signed (1) The corporation rejects the employers’ liability coverage. Brent Dunlop fawconstruction.ia@gmail.com Owner Cedar Falls Black Hawk Iowa Brady Huls Joshua Carder Signed
602 2023-02-16 16:10 Anonymous (not verified) 94.188.207.228 Friday After Work LLC 2526 Rainbow Drive, Cedar Falls, IA 50613 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-01 Brady John Huls brady.cve@gmail.com Cedar Falls Black Hawk Iowa Tyler Reynolds Joshua Carder Signed (1) The corporation rejects the employers’ liability coverage. Brent Dunlop fawconstruction.ia@gmail.com Owner Cedar Falls Black Hawk Iowa Tyler Reynolds Joshua Carder Signed
209 2021-03-19 11:44 Anonymous (not verified) 206.80.128.67 GSW Farms INC 25277 HWY K45 Onawa, IA 51040 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. 2021-03-19 Gregory Willey sgwilley@gmail.com Onawa Monona Iowa Jacob Willey Brad Rock Signed (1) The corporation rejects the employers’ liability coverage. Gregory Willey sgwilley@gmail.com President Onawa Monona Iowa Jacob Willey Brad Rock 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
728 2023-08-03 12:28 Anonymous (not verified) 94.188.205.166 Advanced Plumbing LLC 2538 Carbide Ln, Keokuk, IA 52632 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 James O'Shea advancedplumbing1@yahoo.com Keokuk Iowa United States Rebecca O'Shea Tate O'Shea Signed (1) The corporation rejects the employers’ liability coverage. James O'Shea advancedplumbing1@yahoo.com Partner Keokuk Iowa United States Rebecca O'Shea Tate O'Shea Signed
541 2022-09-23 13:13 Anonymous (not verified) 184.80.177.137 Tim & Lori Daly 25430 New Vienna Rd - Farley, IA 52046 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-23 Tim Daly jheims@english-insurance.com Dyersville Dubuque IA Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque IA Derrick Parsons Joyce Heims Signed
355 2021-11-05 15:04 Anonymous (not verified) 209.252.172.87 S&S Window Treatments Inc. 2555 Hwy 1 SW, Iowa City, IA 52240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-11-20 Joshua Yoder installation@bachmeiercarpetone.com Iowa City Johnson Iowa Heather Howell Sarah Coberley Signed (1) The corporation rejects the employers’ liability coverage. Joshua Yoder installation@bachmeiercarpetone.com Owner Iowa City Johnson Iowa Sarah Coberley Heather Howell Signed
301 2021-08-04 10:05 Anonymous (not verified) 63.142.48.170 Vision Homes Inc 2566 Ivanhoe Rd. SW Cedar Rapids, IA 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-07-02 DeeAnn Nejdl chucknejdl@gmail.com Cedar Rapids Linn Iowa Melanie Heitman Dan Lillis Signed (1) The corporation rejects the employers’ liability coverage. DeeAnn Nejdl chucknejdl@gmail.com Owner Cedar Rapids Linn Iowa Melanie Heitman Dan Lillis Signed
302 2021-08-04 10:08 Anonymous (not verified) 63.142.48.170 Vision Homes Inc 2566 Ivanhoe Rd. SW Cedar Rapids, IA 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-07-02 Charles Nejdl chucknejdl@gmail.com Cedar Rapids Linn Iowa Melanie Heitman Dan Lillis Signed (1) The corporation rejects the employers’ liability coverage. Charles Nejdl chucknejdl@gmail.com Vice President Cedar Rapids Linn Iowa Melanie Heitman Dan Lillis Signed
805 2023-10-31 14:53 Anonymous (not verified) 94.188.207.225 PJ Trucking Unlimited LLC 2617 380th 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. 2023-10-31 Peggy Jensen pegandhalj@gmail.com Farragut Fremont Iowa Julie Marshall Darlene Carpenter Signed (1) The corporation rejects the employers’ liability coverage. Peggy Jensen pegandhalj@gmail.com Member Farragut US US Julie Marshall Darlene Carpenter Signed
811 2023-11-11 11:04 Anonymous (not verified) 94.188.205.175 PJ Trucking Unlimited LLC 2617 380th 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. 2023-11-11 Peggy Jensen pegandhalj@gmail.com Farragut Fremont IA Darlene Carpenter Julie Marshall Signed (1) The corporation rejects the employers’ liability coverage. Peggy Jensen pegandhalj@gmail.com Member Farragut Fremont IA Darlene Carpenter Julie Marshall Signed
555 2022-10-06 17:48 Anonymous (not verified) 67.22.198.94 Baker Irrigation inc 2621 310th 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. 2022-10-08 Daniel Brent Baker dan@bakerirrigationia.com ROCK VALLEY IA United States Adam Kooistra Alex De Jager Signed (1) The corporation rejects the employers’ liability coverage. Daniel Baker dan@bakerirrigationia.com President ROCK VALLEY IA United States Alex DeJager Adam Kooistra Signed
557 2022-10-17 09:23 Anonymous (not verified) 67.22.198.94 Baker Irrigation Inc. 2621 310th St. Rock Valley, IA 51247 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-10-17 Alex DeJager alex@bakerirrigationia.com Rock Valley Sioux Iowa Jesse Niemeyer Herlan DeJager Signed (1) The corporation rejects the employers’ liability coverage. Alex DeJager alex@bakerirrigationia.com Co-Owner Rock Valley Sioux Iowa Jesse Niemeyer Herlan DeJager Signed
558 2022-10-17 09:25 Anonymous (not verified) 67.22.198.94 Baker Irrigation Inc. 2621 310th St. Rock Valley, IA 51247 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-10-17 Daniel Baker dan@bakerirrigationia.com Rock Valley Sioux Iowa Jesse Niemeyer Crystal Brink Signed (1) The corporation rejects the employers’ liability coverage. Alex DeJager alex@bakerirrigationia.com Co-Owner Rock Valley Sioux Iowa Jesse Niemeyer Crystal Brink 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
108 2020-08-19 09:39 Anonymous (not verified) 184.80.177.137 Michelle's Vocational Placement LLC 2642 Farragut Pl., Davenport, IA 52804 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-08-18 Tara Rommel jheims@engish-insurance.com Davenport Scott Iowa Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed
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
791 2023-10-17 16:21 Anonymous (not verified) 94.188.207.229 HEIMGARTNER INSURANCE INC 26511 Hedge 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. 2023-10-17 Travis Heimgarter travis.insure@gmail.com Merrill ia United States Malinda Short Scott Delperdang Signed (1) The corporation rejects the employers’ liability coverage. Travis Heimgarter travis.insure@gmail.com President Merrill ia United States Malinda Short Scott Delperdang Signed
792 2023-10-17 16:23 Anonymous (not verified) 94.188.207.226 HEIMGARTNER INSURANCE INC 26511 Hedge 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. 2023-10-17 Gina Heimgartner travis.insure@gmail.com Merrill ia United States Malinda Short Scott Delperdang Signed (1) The corporation rejects the employers’ liability coverage. Travis Heimgartner travis.insure@gmail.com President Sioux City Iowa United States Malinda Short Scott Delperdang Signed
145 2020-12-18 07:54 Anonymous (not verified) 173.215.16.15 Dohrmann Enterprises Inc 2652 350th Ave DeWitt, IA 52742 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-18 Tom Dohrmann dohrmannpnh@gmail.com DeWitt Clinton Iowa Susanne Owen Daron Oberbroeckling Signed (1) The corporation rejects the employers’ liability coverage. Tom Dohrmann dohrmannpnh@gmail.com Owner DeWitt Clinton Iowa Susanne Owen Daron Oberbroeckling Signed
399 2022-02-03 09:03 Anonymous (not verified) 207.199.230.75 Heart of Iowa Inspections LLC 2700 Highway 63 Oskaloosa Iowa 52577 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-03 Randy DeHeer rdeheer2828@gmail.com Oskaloosa Mahaska Iowa Doris Crile Cheryl Brown Signed (1) The corporation rejects the employers’ liability coverage. Randy DeHeer rdeheer2828@gmail.com self Oskaloosa Mahaska Iowa Doris Crile Cheryl Brown Signed
594 2023-01-31 09:17 Anonymous (not verified) 70.58.136.161 Great Tree LLC 2701 e douglas 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. 2023-01-31 Robert buell Greattree55@gmail.com Des Moines IA United States Jamarlo alvarez Fields Amanda lee netolicky Signed (1) The corporation rejects the employers’ liability coverage. Robert buell Greattree55@gmail.com ceo/ company owner/ operator Des Moines IA United States Jamarlo Alvarez Fields Amanda Lee Netolicky Signed
680 2023-06-06 16:43 Anonymous (not verified) 94.188.205.167 Great Tree LLC 2701 e douglas 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. 2023-06-06 Timothy william Buell tbuell52@gmail.com Des Moines IA United States tyler smith Jamarlo fields Signed (1) The corporation rejects the employers’ liability coverage. Robert buell Greattree55@gmail.com company owner Des Moines IA United States jamarlo fields tyler Smith Signed
920 2024-03-18 15:42 Anonymous (not verified) 94.188.207.223 Great Tree LLC 2701 e douglas 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. 2024-03-18 Robert buell Greattree55@gmail.com Des Moines IA United States ryan homan Jamarlo fields Signed (1) The corporation rejects the employers’ liability coverage. Robert buell Greattree55@gmail.com company owner Des Moines IA United States ryan homan jamarlo fields Signed
921 2024-03-18 15:45 Anonymous (not verified) 94.188.207.226 Great Tree LLC 2701 e douglas 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. 2024-03-18 Timothy Buell treeshark52@gmail.com Des Moines IA United States ryan homan Jamarlo fields Signed (1) The corporation rejects the employers’ liability coverage. Robert buell Greattree55@gmail.com company owner Des Moines IA United States ryan homan jamarlo fields Signed
45 2020-03-10 10:24 Anonymous (not verified) 204.141.214.180 Shamrock Screenprinting Inc 2710 Granite Ct 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. 2020-03-10 Lori Handley lori.handley@aol.com Cedar Rapids Linn IA David Handley Beth Barta Signed (1) The corporation rejects the employers’ liability coverage. Lori Handley lori.handley@aol.com VP Cedar Rapids Linn IA David Handley Beth Barta Signed
46 2020-03-10 10:26 Anonymous (not verified) 204.141.214.180 Shamrock Screenprinting Inc 2710 Granite Ct 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. 2020-03-10 David Handley davehandley53@gmail.com Cedar Rapids Linn IA Lori Handley Beth Barta Signed (1) The corporation rejects the employers’ liability coverage. Lori Handley Lori.handley@aol.com VP Cedar Rapids Linn IA Lori Handley Beth Barta Signed
448 2022-04-19 15:15 Anonymous (not verified) 184.80.177.137 Andrew Lemke DBA: TAP Fabrication 27214 218th Street, Earlville, IA 52041 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-08 Andrew Lemke jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
758 2023-08-29 11:56 Anonymous (not verified) 94.188.207.229 Ellison building and repair 2722 645th moravia IA 52571 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. 2023-08-18 Keeton Ellison keeton2005@gmail.com Moravia Appanoose Iowa Cory Ellison Sammy Ellison Signed (1) The corporation rejects the employers’ liability coverage. Sammy Ellison sammyllsn@yahoo.com Mom Moravia Monroe Iowa Cory Ellison Sammy Ellison Signed
678 2023-06-06 10:28 Anonymous (not verified) 94.188.205.177 William Terrance Harshbarger Jr. 27225 115th Avenue, Donahue IA 52746 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-06 William Terrance Harshbarger Jr. harzyhd1@hotmail.com Donahue Scott Iowa Margaret Tucker Cheryl Piersall Signed (1) The corporation rejects the employers’ liability coverage. William Terrance Harshbarger Jr. harzyhd1@hotmail.com self Donahue Scott Iowa Margaret Tucker Cheryl Piersall Signed
679 2023-06-06 10:36 Anonymous (not verified) 94.188.205.174 William Terrance Harshbarger Jr. 27225 115th Avenue, Donahue IA 52746 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-06 William Terrance Harshbarger Jr. harzyhd1@hotmail.com Donahue Scott Iowa Margaret Tucker Cheryl Piersall Signed (1) The corporation rejects the employers’ liability coverage. William Terrance Harshbarger Jr. harzyhd1@hotmail.com self Donahue Scott Iowa Margaret Tucker Cheryl Piersall 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
969 2024-05-02 16:15 Anonymous (not verified) 94.188.205.175 Adamantine Spine Moving 2726 Independence Rd Iowa City, IA 52240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-02 John Clifford Wallace cliff.wallace@spinemoving.com Des Moines Polk Iowa John Thomas Wallace Amanda Root Wallace Signed (1) The corporation rejects the employers’ liability coverage. Bill Hoke bill.hoke@spinemoving.com HR Des Moines Polk County Sarah Mannix Erika Banks Signed
643 2023-03-30 09:58 Anonymous (not verified) 94.188.205.175 Adamantine Spine Moving 2726 Independence Rd., Iowa City, IA 52240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-30 Emily Wallace emily.wallace@spinemoving.com Des Moines Polk Iowa John Wallace Ashley Koch Signed (1) The corporation rejects the employers’ liability coverage. Ashley Koch ashley.koch@spinemoving.com Human Resources Manager West Des Moines Polk Iowa John Wallace Taylor Roth Signed
970 2024-05-02 16:15 Anonymous (not verified) 94.188.205.167 Adamantine Spine Moving 2726 Independence Rd., Iowa City, IA 52240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-02 Emily Wallace emily.wallace@spinemoving.com Des Moines Polk Iowa Margaret Walter Dan Walter Signed (1) The corporation rejects the employers’ liability coverage. William Hoke bill.hoke@spinemoving.com Owner Iowa City Johnson Iowa Sarah Mannix Erika Banks Signed
642 2023-03-30 09:56 Anonymous (not verified) 94.188.205.174 Adamantine Spine Moving 2726 Independence Road Iowa City, Iowa 52240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-30 John Clifford Wallace cliff.wallace@spinemoving.com Des Moines Polk IA Taylor Christian Roth Ashley Anne Koch Signed (1) The corporation rejects the employers’ liability coverage. Ashley Anne Koch ashley.koch@spinemoving.com HR, Safety and Compliance Manager Des Moines Polk Iowa Taylor Christian Roth John Clifford Wallace Signed
956 2024-04-12 14:23 Anonymous (not verified) 205.221.255.62 All things power wash ATP LLC 2730 Lafayette, Sioux City, IA 51104 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. 2024-04-12 Anthony Rowe allthingspowerwash4usiouxcity@gmail.com Sioux City Woodbury Iowa Franzis Rios Tamara Bawi Signed (1) The corporation rejects the employers’ liability coverage. Anthony Rowe allthingspowerwash4usiouxcity@gmail.com Owner Sioux City Woodbury Iowa Franzis Rios Tamara Bawi Signed
744 2023-08-17 11:25 Anonymous (not verified) 94.188.207.225 NIEMEYER WELL AND PUMP INC 2735 GARFIELD AVE, HULL IA 51239 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. 2023-08-15 TYLER NIEMEYER neighborhoodpump@gmail.com CANTON LINCOLN SD JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The corporation rejects the employers’ liability coverage. TYLER NIEMEYER neighborhoodpump@gmail.com SELF CANTON LINCOLN SD JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed