480 |
2022-05-30 11:37 |
Anonymous (not verified) |
134.215.6.237 |
Access Property Management Corp DBA Wine & Spirits |
510 E Carrington Ln, Appleton, WI 54913 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-30 |
Lisa M Ricklefs |
lisarick19@yahoo.com |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferek |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Thomas Ricklefs |
tjrick@yahoo.com |
President |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferak |
Signed |
481 |
2022-05-30 11:42 |
Anonymous (not verified) |
134.215.6.237 |
Access Property Management Corp DBA Wine & Spirits |
510 E Carrington Ln, Appleton, WI 54913 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-30 |
Thomas J Ricklefs |
tjrick@yahoo.com |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferek |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa M Ricklefs |
lisarick19@yahoo.com |
VP |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferek |
Signed |
215 |
2021-03-29 07:58 |
Anonymous (not verified) |
173.18.193.51 |
Lee County Fair, Inc |
PO Box 179 |
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. |
2021-03-05 |
Dillon Benner |
judy@fullenkampins.com |
ARgyle |
IA |
United States |
Lindsey Lampe |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dillon Benner |
judy@fullenkampins.com |
Board Member |
Argyle |
IA |
United States |
Lindsey Lampe |
Judy Moeller |
Signed |
223 |
2021-03-29 08:11 |
Anonymous (not verified) |
173.18.193.51 |
Lee County Fair, Inc |
PO Box 179, Donnellson, 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. |
2021-03-04 |
Tammy LeMaster |
judy@fullenkampins.com |
Argyle |
Lee |
iowa |
Lindsey Lampe |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tammy LeMaster |
judy@fullenkampins.com |
Board Member |
ARgyle |
Lee |
Iowa |
Lindsey Lampe |
Judy Moeller |
Signed |
66 |
2020-04-20 13:41 |
Anonymous (not verified) |
173.24.181.211 |
Historic Arnolds Park Inc |
37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-01 |
Tresa Hussong |
jennifer@walkerinsuranceia.com |
Arnolds Park |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tresa Hussong |
jennifer@walkerinsuranceia.com |
Board Member |
Arnolds Park |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
235 |
2021-04-14 13:18 |
Anonymous (not verified) |
173.31.147.225 |
HISTORIC ARNOLDS PARK INC |
37 LAKE ST ARNOLDS PARK, IA 51331 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-14 |
LANCE EVANS |
joel@walkerinsuranceia.com |
ARNOLDS PARK |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
JEFF VIERKANT |
Jeff@arnoldspark.com |
CEO |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JEFF VIERKANT |
Signed |
579 |
2022-12-07 14:37 |
Anonymous (not verified) |
96.31.1.206 |
IGL RENTAL LLC |
PO BOX 317 ARNOLDS PARK IA 51331 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-10-25 |
CHAD JONES |
STAYBOJI@GMAIL.COM |
ARNOLDS PARK |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CHAD JONES |
STAYBOJI@GMAIL.COM |
MEMBER |
ARNOLDS PARK |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
461 |
2022-05-02 11:08 |
Anonymous (not verified) |
192.119.212.86 |
Iceberg Enterprises LLC |
101 E. 1st street Arthur IA 51431 |
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 |
Jesse Bergman |
jk_montana@yahoo.com |
arthur |
Iowa |
United States |
Maren Smith |
Darren Smith |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Katherine Bergman |
jk_montana@yahoo.com |
Owner |
Arthur |
IOWA |
United States |
Susan Bergman |
Jesse Bergman |
Signed |
375 |
2021-12-23 12:23 |
Anonymous (not verified) |
66.230.245.47 |
W. R. Elliot & Associates, Ltd. |
3306 Brook Hollow Dr, Asbury, IA 52002 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-12-23 |
William R. Elliot |
bill@wreassoc.com |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L. Spalla |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William R. Elliot |
bill@wreassoc.com |
President |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L Spalla |
Signed |
376 |
2021-12-29 14:40 |
Anonymous (not verified) |
66.230.245.47 |
W. R. Elliot & Associates, Ltd. |
3306 Brook Hollow Dr, Asbury, IA 52002 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-12-29 |
Karen R. Elliot |
karen@handiwerks.com |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L Spalla |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William R. Elliot |
bill@wreassoc.com |
President |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L Spalla |
Signed |
774 |
2023-09-21 10:21 |
Anonymous (not verified) |
94.188.205.167 |
Tri State Trucking LLC |
47282 US Hwy 20 Atkinson, NE 68713 |
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. |
2023-09-21 |
Casey Schaaf |
casey@tri-statetrucking.com |
Atkinson |
Holt |
NE |
Angela Schaaf |
Crystal Osborne |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Casey Schaaf |
casey@tri-statetrucking.com |
Owner |
Atkinson |
Holt |
NE |
Angela Schaaf |
Crystal Osborne |
Signed |
570 |
2022-11-16 10:35 |
Anonymous (not verified) |
50.81.253.108 |
XU's Golden Dragon |
508 Chestnut St., Atlantic, IA 50022 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-11-16 |
Xu Long |
125529647@QQ.COM |
Atlantic |
Cass |
IA |
Richard Crall |
Shannon Crall |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Richard Crall |
richard@partnersins.com |
Insurance Agent |
Atlantic |
Cass |
United States |
Shannon Crall |
Richard Crall |
Signed |
571 |
2022-11-16 10:40 |
Anonymous (not verified) |
50.81.253.108 |
XU's Golden Dragon |
508 Chestnut St., Atlantic, IA 50022 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-11-16 |
Tingjie Huang |
125529647@QQ.COM |
Atlantic |
Cass |
IA |
Richard Crall |
Shannon Crall |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Richard Crall |
richard@partnersins.com |
Insurance Agent |
Atlantic |
Cass |
United States |
Shannon Crall |
Richard Crall |
Signed |
247 |
2021-04-27 09:35 |
Anonymous (not verified) |
207.191.206.210 |
United windows and siding |
4080 1st Avenue NE, Cedar Rapids Iowa 52402 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2021-04-27 |
Adrian Sanchez |
adrian@unitedwindowsandsiding.com |
Aurora |
CO |
United States |
Megan Bierley |
Ginger Berens |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Adrian Sanchez |
adrian@unitedwindowsandsiding.com |
Owner |
Aurora |
Jeffereson |
CO |
Megan Bierley |
Ginger Berens |
Signed |
464 |
2022-05-06 10:15 |
Anonymous (not verified) |
172.86.44.178 |
Cornhill Express LLC |
6472 40th St, Aurora, IA 50607 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-06 |
Jamie Fettkether |
sales@cherepair.com |
Aurora |
Buchanan |
Iowa |
Ben Hogan |
Ryan Peyton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jamie Fettkether |
sales@cherepair.com |
Owner |
Aurora |
Buchanan |
Iowa |
Ben Hogan |
Ryan Peyton |
Signed |
714 |
2023-07-25 16:16 |
Anonymous (not verified) |
94.188.207.224 |
Midwest Systems |
2877 130th St Aurora, Ia 50607 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-07-25 |
Matt Griswold |
midwestsystems@live.com |
Aurora |
IA |
United States |
Creatleigh Griswold |
Carslyn Griswold |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Matt Griswold |
midwestsystems@live.com |
Owner |
Aurora |
IA |
United States |
Creatleigh Griswold |
Carslyn Griswold |
Signed |
529 |
2022-09-01 13:53 |
Anonymous (not verified) |
72.131.73.148 |
Sozo Companies, Inc. |
23751 Hoover Road, Warren MI 48089 |
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. |
2022-09-01 |
Aaron Rasty |
arasty@sozocompanies.com |
Austin |
Travis |
Texas |
Robert Davis |
Paul Huth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Aaron Rasty |
arasty@sozocompanies.com |
President |
Austin |
Travis |
Texas |
Robert Davis |
Paul Huth |
Signed |
457 |
2022-04-29 08:21 |
Anonymous (not verified) |
107.126.24.57 |
Thatcher Auto Center INC |
406 S West ave Baxter, IA 50028 |
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 |
Nathan Doubek |
thatcherautocenter@gmail.com |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rick Thatcher |
rickswrecks@gmail.com |
President |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
458 |
2022-04-29 08:26 |
Anonymous (not verified) |
107.126.24.57 |
Thatcher Auto Center INC |
406 S West ave Baxter Iowa 50028 |
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 |
Richard Thatcher |
rickswrecks@gmail.com |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nathan Doubek |
thatcherautocenter@gmail.com |
Vice President |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
765 |
2023-09-12 12:44 |
Anonymous (not verified) |
94.188.207.229 |
Southwest Sanitation Inc |
Clarinda, 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. |
2023-09-12 |
Lindsay A Schrock |
swsanitation@gmail.com |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lindsay Schrock |
swsanitation@gmail.com |
Treasure |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
766 |
2023-09-12 12:46 |
Anonymous (not verified) |
94.188.207.224 |
Southwest Sanitation |
Clarinda, 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. |
2023-09-12 |
Craig Schrock |
swsanitation@gmail.com |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lindsay Schrock |
swsanitation@gmail.com |
Treasure |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
767 |
2023-09-12 12:48 |
Anonymous (not verified) |
94.188.207.223 |
Southwest Sanitation |
Clarinda, 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. |
2023-09-12 |
Lonnie Weed |
swsanitation@gmail.com |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lindsay Schrock |
swsanitation@gmail.com |
Treasure |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
769 |
2023-09-12 12:49 |
Anonymous (not verified) |
94.188.207.223 |
Southwest Sanitation |
Clarinda, 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. |
2023-09-12 |
Joshua Weed |
swsanitation@gmail.com |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lindsay Schrock |
swsanitation@gmail.com |
Treasure |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
231 |
2021-04-11 12:19 |
Anonymous (not verified) |
174.243.115.140 |
Blaser Plumbing Inc |
28933 Sieverding Ridge Rd Bellevue IA 52031 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-11 |
Michael Blaser |
bpi1999@hotmail.com |
Bellevue |
IA |
United States |
Joyce Langmeier |
Sylvester Langmeier |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Blaser |
bpi1999@hotmail.com |
Owner |
Bellevue |
IA |
United States |
Joyce Langmeier |
Sylvester Langmeier |
Signed |
585 |
2022-12-15 20:32 |
Anonymous (not verified) |
192.110.196.132 |
Maywood Enterprises, Inc. |
28345 Highway 52, Bellevue, IA 52031 |
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. |
2022-12-15 |
Ann L Wachtel |
annw@financepro123.com |
Bellevue |
Jackson |
Iowa |
Katie Laban |
Jeffrey Laban |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ann L Wachtel |
annw@financepro123.com |
President |
Bellevue |
Jackson |
IA |
Katie Laban |
Jeffrey Laban |
Signed |
645 |
2023-03-31 08:55 |
Anonymous (not verified) |
94.188.205.166 |
3Fitt Life, Inc. |
28345 Highway 52, Bellevue, IA 52031 |
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. |
2023-03-31 |
Ann L Wachtel |
annw@3fitt.com |
Bellevue |
Jackson |
Iowa |
Jeff Laban |
Katie Laban |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ann L Wachtel |
annw@3fitt.com |
President |
Bellevue |
Jackson |
Iowa |
Jeff Laban |
Katie Laban |
Signed |
160 |
2021-01-13 10:52 |
Anonymous (not verified) |
173.190.64.239 |
united workers inc |
711 4th st 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. |
2021-01-13 |
mayra sapolvada |
buck@trvnet.net |
Belmond |
wright |
iowa |
shannon muhlenbruch |
Martha Leal |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
mayra sapulvada |
buck@trvnet.net |
president |
belmond |
wright |
ia |
shannon myhlenbruch |
martha leal |
Signed |
899 |
2024-02-25 18:18 |
Anonymous (not verified) |
94.188.207.229 |
Michael D Clark |
324 main st Bennett Iowa 52721 |
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. |
2024-02-25 |
Michael D Clark |
michaeld3705@gmail.com |
Bennett |
Cedar |
Iowa |
Davia Dawn Kelley |
Tabetha Jean Widmer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael D Clark |
michaeld3705@gmail.com |
Owner |
Bennett |
Cedar |
Iowa |
Davia Dawn Kelley |
Tabetha Jean Widmer |
Signed |
586 |
2022-12-16 15:53 |
Anonymous (not verified) |
184.184.197.146 |
Halide Biologics |
330 Golfview Ave, Iowa City IA 52246 |
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. |
2022-12-15 |
Daniel Infield |
danielinfield@gmil.com |
Bennington |
Douglas |
Nebraska |
Alexander Estell |
Jesse Herrera |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Infield |
danielinfield@gmail.com |
President |
Bennington |
NE |
United States |
Alexander Estell |
Jesse Herrera |
Signed |
839 |
2023-12-18 16:12 |
Anonymous (not verified) |
94.188.207.227 |
515 Painting llc |
po box 157 |
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. |
2023-12-18 |
Marvin S Parker JR |
stvpkr@gmail.com |
berwick |
polk |
iowa |
Christopher Eldridge |
Dillon Parker |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Marvin parker |
stvpkr@gmail.com |
owner |
berwick |
Polk |
Iowa |
Christopher Eldridge |
Dillon Parker |
Signed |
59 |
2020-04-14 12:54 |
Anonymous (not verified) |
65.126.161.162 |
Elite Carpentry |
1515 21st Street Bettendorf, IA 52722 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-10 |
Jeffrey D. Leech |
elitecarpentryqc@gmail.com |
Bettendorf |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Jeffrey D. Leech |
elitecarpentryqc@gmail.com |
President |
Bettendorf |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
95 |
2020-07-02 10:30 |
Anonymous (not verified) |
206.125.132.254 |
Dave Prochaska Construction |
5848 Hopeview Ct |
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. |
2020-07-02 |
Dave Prochaska |
kschepers@nelsonbrothersagency.com |
Bettendorf |
Scott |
IA |
Kaitlin Schepers |
Lori Fisher |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dave Prochaska |
kschepers@nelsonbrothersagency.com |
Owner |
Bettendorf |
Scott |
IA |
Kaitlin Schepers |
Lori Fisher |
Signed |
148 |
2020-12-30 08:22 |
Anonymous (not verified) |
166.181.83.201 |
Elite Carpentry |
P.O. Box 1162 Bettendorf Iowa 52722 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-30 |
Jeffrey D Leech |
Elitecarpentryqc@gmail.com |
Bettendorf |
Scott |
Iowa |
Jeremy Havens |
Michael Rodriguez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffrey D Leech |
Elitecarpentryqc@gmail.com |
Owner |
Bettendorf |
Scott |
Iowa |
Jeremy Havens |
Michael Rodriguez |
Signed |
709 |
2023-07-17 15:46 |
Anonymous (not verified) |
94.188.205.166 |
Breuer Roofing Company |
3021 Sunburst Dr. Bettendorf, IA 52722 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-07-17 |
Chad Breuer |
chadbreuer@gmail.com |
Bettendorf |
Scott |
IA |
Caroline Kristina Breuer |
Patricia Ann Breuer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chad Michael Breuer |
chadbreuer@gmail.com |
President |
Bettendorf |
Scott |
IA |
Caroline Kristina Breuer |
Patricia Ann Breuer |
Signed |
712 |
2023-07-24 12:34 |
Anonymous (not verified) |
94.188.205.168 |
BOG Roofing |
3768 Deerbrook Dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-07-24 |
Devon Booton |
devonboot1973@gmail.com |
Bettendorf |
Iowa |
United States |
Viviana Gonzalez |
Shannon Wolever |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Devon Booton |
devonboot1973@gmail.com |
Self |
Bettendorf |
Iowa |
United States |
Viviana Gonzalez |
Shannon Wolever |
Signed |
740 |
2023-08-14 10:25 |
Anonymous (not verified) |
94.188.205.167 |
Absolute Mud Jacking Inc |
5038 Brittany Ct Bettendorf Iowa 52722 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-12 |
Paul Pelzer |
pelzer830@gmail.com |
Bettendorf |
IA |
United States |
Brett Lewandowski |
Phil Schaefer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Pelzer |
pelzer830@gmail.com |
Owner |
Bettendorf |
IA |
United States |
Brett Lewandowski |
Phil Schaefer |
Signed |
908 |
2024-03-02 14:33 |
Anonymous (not verified) |
94.188.207.230 |
Gerlich Enterprises |
2824 Hickory Hills Ln |
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. |
2024-03-02 |
Paul Gerlich |
paul@gerlich.io |
Bettendorf |
scott |
IA |
Kelsey Gerlich |
Elora Gerlich |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Gerlich |
paul@gelrich.io |
Owner |
Bettendorf |
Scott |
Iowa |
Kelsey Gerlich |
Garrett Gerlich |
Signed |
909 |
2024-03-02 14:33 |
Anonymous (not verified) |
94.188.207.224 |
Gerlich Enterprises |
2824 Hickory Hills Ln |
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. |
2024-03-02 |
Kelsey Gerlich |
paul@gerlich.io |
Bettendorf |
scott |
IA |
Paul Gerlich |
Elora Gerlich |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Gerlich |
paul@gelrich.io |
Owner |
Bettendorf |
Scott |
Iowa |
Elora Gerlich |
Garrett Gerlich |
Signed |
910 |
2024-03-02 14:34 |
Anonymous (not verified) |
94.188.207.224 |
Gerlich Enterprises |
2824 Hickory Hills Ln |
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. |
2024-03-02 |
Elora Gerlich |
paul@gerlich.io |
Bettendorf |
scott |
IA |
Paul Gerlich |
Kelsey Gerlich |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Gerlich |
paul@gelrich.io |
Owner |
Bettendorf |
Scott |
Iowa |
Kelsey Gerlich |
Garrett Gerlich |
Signed |
911 |
2024-03-02 14:34 |
Anonymous (not verified) |
94.188.205.168 |
Gerlich Enterprises |
2824 Hickory Hills Ln |
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. |
2024-03-02 |
Garrett Gerlich |
paul@gerlich.io |
Bettendorf |
scott |
IA |
Paul Gerlich |
Kelsey Gerlich |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Gerlich |
paul@gelrich.io |
Owner |
Bettendorf |
Scott |
Iowa |
Kelsey Gerlich |
Elora Gerlich |
Signed |
952 |
2024-04-08 17:25 |
Anonymous (not verified) |
94.188.205.175 |
Bio-Inspired Design Aeronautics Corp |
6843 Still Creek Pass |
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 |
Joseph Mitchell |
aerotech@hush.com |
Bettendorf |
Iowa |
United States |
Mike Owens |
Chris DeCock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Hollie Mitchell |
mitchhollie@yahoo.com |
Vice President |
Bettendorf |
Iowa |
United States |
Mike Owens |
Chris DeCock |
Signed |
953 |
2024-04-08 17:35 |
Anonymous (not verified) |
94.188.205.174 |
Bio-Inspired Design Aeronautics Corp |
6843 Still Creek Pass |
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 |
Hollie Mitchell |
mitchhollie@yahoo.com |
Bettendorf |
Iowa |
United States |
Mike Owens |
Chris DeCock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph Mitchell |
aerotech@hush.com |
President |
Bettendorf |
Iowa |
United States |
Mike Minnich |
Chris DeCock |
Signed |
954 |
2024-04-08 17:38 |
Anonymous (not verified) |
94.188.205.168 |
Bio-Inspired Design Aeronautics Corp |
6843 Still Creek Pass |
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 |
Hailey Mitchell |
hailey8.hm@hush.com |
Bettendorf |
Iowa |
United States |
Mike Owens |
Chris DeCock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph Mitchell |
aerotech@hush.com |
President |
Bettendorf |
Iowa |
United States |
Mike Minnich |
Chris DeCock |
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 |
683 |
2023-06-09 14:03 |
Anonymous (not verified) |
94.188.207.228 |
Fire & Ice Heating and Cooling |
6040 114th St, Blue Grass IA 52726 |
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. |
2023-06-09 |
Todd Ruckoldt |
ruckoldt1@icloud.com |
Blue Grass |
Scott |
Iowa |
Eric Ruckoldt |
Tyler Ruckoldt |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Javier Gonzalez |
javier@qcinsured.com |
Agent |
Davenport |
Scott |
Iowa |
Eric Ruckoldt |
Tyler Ruckoldt |
Signed |
809 |
2023-11-08 09:47 |
Anonymous (not verified) |
94.188.207.229 |
GruntWorkz Wedling and Fab, Inc. |
15519 80th Ave Blue Grass, IA 52726 |
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. |
2023-11-08 |
Brandon Joseph Fox |
GruntWorkzwelding@gmail.com |
Blue Grass |
Scott |
Iowa |
Amanda Dawn Fox |
Brandon Joseph Fox |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brandon Joseph Fox |
GruntWorkzwelding@gmail.com |
Same Person |
Blue Grass |
Scott |
Iowa |
Amanda Dawn Fox |
Brandon Joseph Fox |
Signed |
216 |
2021-03-29 08:01 |
Anonymous (not verified) |
173.18.193.51 |
Lee County Fair, Inc |
PO Box 179, Donnellson, 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. |
2021-03-03 |
Bryan Bredemeyer |
judy@fullenkampins.com |
Bonaparte |
IA |
United States |
Lindsey Lampe |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brian Bredemeyer |
judy@fullenkampins.com |
Board Member |
Bonaparte |
IA |
United States |
Lindsey Lampe |
Judy Moeller |
Signed |
89 |
2020-06-10 11:42 |
Anonymous (not verified) |
173.28.7.32 |
DMG INSTALLATIONS INC |
5534 NE 17TH ST #4 |
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. |
2020-06-10 |
JASON DAVID MUSSO |
JMUSSO74@GMAIL.COM |
BONDURANT |
POLK |
IOWA |
DAVID PAUL DUNLAP |
CLIFFORD LEE BAKER |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CLIFFORD LEE BAKER |
CLBAKER@MEDIACOMBB.NET |
PRESIDENT |
ALTOONA |
POLK |
IOWA |
JASON DAVID MUSSO |
DAVID PAUL DUNLAP |
Signed |
801 |
2023-10-25 08:32 |
Anonymous (not verified) |
94.188.205.177 |
CEM Businesses LLC |
608 Evergreen Cir NW Bondurant, IA 50035 |
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. |
2022-10-25 |
Dane McDonald |
danemcdonald2@gmail.com |
Bondurant |
Polk |
Iowa |
Raelynn Aicher |
Cameron VanBuren |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dane McDonald |
dane.mcdonald@stellar-solar.net |
Self |
Bondurant |
Polk |
Iowa |
Raelynn Aicher |
Cameron VanBuren |
Signed |