154 |
2021-01-06 13:23 |
Anonymous (not verified) |
167.142.147.6 |
PACIFIC DRYWALL CORPORATION |
105 SNYDER DRIVE HUXLEY, IOWA 50124 |
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. |
2021-01-06 |
LUIS MANUEL AVALOS CASTELANOS |
PACIFICDRYWALLCORP@GMAIL.COM |
DES MOINES |
POLK |
IOWA |
JENNIFER LYNNE ESCOBAR |
JUAN JOSE AVALOS CASTELLANOS |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
LUIS MANUEL AVALOS CASTELANOS |
PACIFICDRYWALLCORP@GMAIL.COM |
PRESIDENT |
DES MOINES |
POLK |
IOWA |
JUAN JOSE AVALOS CASTELLANOS |
JENNIFER LYNNE ESCOBAR |
Signed |
176 |
2021-02-03 15:02 |
Anonymous (not verified) |
174.198.90.166 |
Jesse's Embers LLC |
3301 Ingersoll Ave, Des Moines, IA, 50312 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-03 |
Deena Edelstein |
dledelstein@hotmail.com |
Des Moines |
Polk |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Deena Edelstein |
dledelstein@hotmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
177 |
2021-02-03 15:07 |
Anonymous (not verified) |
174.198.90.166 |
Jesse's Embers LLC |
3301 Ingersoll Ave, Des Moines, IA, 50312 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-03 |
Martin Scarpino |
martyscarpino@yahoo.com |
Des Moines |
Polk |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Martin Scarpino |
martyscarpino@yahoo.com |
Owner |
Des Moines |
IA |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
178 |
2021-02-13 00:06 |
Anonymous (not verified) |
172.58.87.80 |
All Cut Lawncare and Landscaping LLC |
3506 Glover Ave. Des Moines Iowa 50315 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-12 |
Michael David Money |
moneymichael811@gmail.com |
Des Moines |
Polk |
Iowa |
Diana Jennings |
Deanna L Phagan |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael David Miney |
mineymichael811@gmail.com |
Owner and President |
Des Moines |
Polk |
Iowa |
Diana Jennings |
Deanna L Phagan |
Signed |
206 |
2021-03-12 12:19 |
Anonymous (not verified) |
173.17.248.17 |
Luna & Barreto Inc |
5825 Urbandale Ave., Des Moines, IA 50322 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-04 |
Mario Barreto |
lunaybarreto68@gmail.com |
Des Moines |
Polk |
IA |
Flavio Ortiz |
MariCarmen Cueto |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mario Barreto |
lunaybarreto68@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Flavio Ortiz |
MariCarmen Cueto |
Signed |
230 |
2021-04-06 21:15 |
Anonymous (not verified) |
173.23.145.187 |
Jose J Framing |
5301 SE 24th St. 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. |
(2) I decline to reject the employer’s liability coverage. |
2021-01-01 |
Jose J. Castillo |
castillojosejonathan7@gmail.com |
Des Moines |
Polk |
United States |
Perla Landaverde Garcia |
Alma Y. Gaytan |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Jose J. Castillo |
castillojosejonathan7@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Perla Landaverde Garcia |
Alma Y. Gaytan |
Signed |
262 |
2021-05-06 12:50 |
Anonymous (not verified) |
65.158.43.250 |
Maxter Roofing INC |
4112 E 14th St Des Moines, IA 50313 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-06 |
Gilberto Mata DBA Maxter Roofing INC |
oliviazavala120@yahoo.com |
Des Moines |
Polk |
IA |
Josh Bolton |
Olivia Zavala |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gilberto Mata DBA Maxter Roofing INC |
oliviazavala120@yahoo.com |
Owner |
Des Moines |
POLK |
IA |
Josh Bolton |
Olivia Zavala |
Signed |
265 |
2021-05-22 13:33 |
Anonymous (not verified) |
75.162.162.238 |
Superior Painting and Remodeling, corp |
8415 Franklin Ave. Apt. 49 Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-22 |
Luz Maria Morales Gutierrez |
lm3673719@gmial.com |
Des Moines |
USA |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Luz Maria Morales Gutierrez |
lm3673719@gmial.com |
Owner |
Des Moines |
USA |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
266 |
2021-05-22 13:38 |
Anonymous (not verified) |
75.162.162.238 |
Superior Painting and Remodeling, corp |
8415 Franklin Ave. Apt. 49 Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-22 |
Elmer Lopez Montufar |
lm3673719@gmial.com |
Des Moines |
USA |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Superior Painting and Remodeling Corp |
lm3673719@gmial.com |
Owner |
Des Moines |
USA |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
283 |
2021-06-30 14:24 |
Anonymous (not verified) |
75.162.212.130 |
Superior Painting and Remodeling, corp |
8415 Franklin Ave Apt 49 Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-06-30 |
Luz Maria Morales Gutierrez |
lm3673719@gmail.com |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Luz Maria Morales Gutierrez |
lm3673719@gmail.com |
Owner |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
284 |
2021-06-30 14:27 |
Anonymous (not verified) |
75.162.212.130 |
Superior Painting and Remodeling, corp |
8415 Franklin Ave Apt 49 Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-06-30 |
Elmer Lopes Montufar |
lm3673719@gmail.com |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Superior Painting and Remodeling Corp |
lm3673719@gmail.com |
Owner |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
285 |
2021-06-30 14:33 |
Anonymous (not verified) |
75.162.212.130 |
Superior Painting and Remodeling, corp |
8415 Franklin Ave Apt 49 Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-06-30 |
Luz Maria Morales Gutierrez |
lm3673719@gmail.com |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Superior Painting and Remodeling Corp |
lm3673719@gmail.com |
Owner |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
295 |
2021-07-27 15:13 |
Anonymous (not verified) |
75.162.64.21 |
Homars Concrete Inc. |
2439 se 19th st 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. |
2021-07-16 |
Omar Sacramento |
yasiel558@gmail.com |
Des Moines |
Polk |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Omar Sacramento |
yasiel558@gmail.com |
owner |
Des Moines |
polk |
iowa |
liliana sanchez |
yolanda mendoza |
Signed |
299 |
2021-08-02 10:55 |
Anonymous (not verified) |
97.125.35.240 |
L:ion BUilder Construction,, INC |
1705 E 32nd St Des Moines, Iowa 50317 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-07-24 |
Carlos E Mondoza-Gutierrez |
gutierrezce1992@icloud.com |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Juana M.R. |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Carlos E Mendoz-Gutierrez |
gutierrezce1992@icloud.com |
self |
Des Moines |
Polk |
Iowa |
Juan M. R. |
Debra Stratton |
Signed |
300 |
2021-08-03 12:43 |
Anonymous (not verified) |
97.125.35.240 |
Every Solutions Drywall INC |
713 SE 7th St Des Moines, Iowa 50309 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-03 |
Luis Hernandez |
everysolutiondrywainc@yahoo.com |
Des Moines |
Polk |
Iowa |
Kelly Denger |
Debra Stratton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Luis Hernandez |
everysoloutiondrywainc@yahoo.com |
Owner |
Des Moines |
Polk |
Ia |
Kelly Denger |
Debra Stratton |
Signed |
308 |
2021-08-13 15:23 |
Anonymous (not verified) |
65.154.100.34 |
World of Reptiles Inc dba Snakes Alive |
3901 NW Seasons Ct Ankeny, IA 50023 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-09 |
Tom Weidner |
mmatlock@thedanaco.com |
Des Moines |
Polk |
IA |
Megan Matlock |
Ron Goodman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tom Weidner |
mmatlock@thedanaco.com |
Owner |
Des Moines |
Polk |
IA |
Megan Matlock |
Ron Goodman |
Signed |
332 |
2021-09-13 13:30 |
Anonymous (not verified) |
173.23.250.91 |
Cheri’s roofing |
230 palomino pkwy Des Moines Iowa 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2021-09-13 |
Cheryl Martinez |
cheri6876@yahoo.com |
Des Moines |
Polk |
Iowa |
Cheryl Martinez |
Cheryl martinez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chery Martinez |
cheri6876@yahoo.com |
Owner |
Des Moines |
Polk |
Iowa |
Cheryl Martinez |
Cheryl Martinez |
Signed |
401 |
2022-02-08 11:16 |
Anonymous (not verified) |
173.29.121.248 |
NW Bender LLC DBA Agent Clean |
3229 E Ovid 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. |
2022-02-07 |
Nikolas W Bender |
Nikolas@agentclean.com |
Des Moines |
Polk |
Iowa |
Stan Mohr |
Victor Flores |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nikolas W Bender |
Nikolas@agentclean.com |
Self |
Des Moines |
Polk |
Iowa |
Stan Mohr |
Victor Flores |
Signed |
410 |
2022-02-20 19:10 |
Anonymous (not verified) |
173.27.233.68 |
A and W marble and tile Inc |
207 Philip St. Des Moines, Iowa 50315 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-02-20 |
Wayne Yergy |
wyergy@gmail.com |
Des Moines |
Polk |
Iowa |
John Noga |
Angie Carter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Wayne A Yergy |
wyergy@gmail.com |
Vice President |
Des Moines |
IA |
United States |
John Noga |
Angie Carter |
Signed |
440 |
2022-03-29 20:05 |
Anonymous (not verified) |
174.215.228.20 |
Navarro construction |
2825 SE 14th St lot #6 |
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 |
Enrique Navarro |
enriquenavarro887@gmail.com |
Des Moines |
Polk |
IA |
Alondra Navarro |
René Navarro |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Enrique Navarro |
enriquenavarro884@gmail.com |
Owner |
Des moines |
Polk |
IA |
Alondra Navarro |
René Navarro |
Signed |
456 |
2022-04-29 08:14 |
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 |
Matthew Lee Wells |
Praynostop@msn.com |
Des Moines |
Polk |
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 |
467 |
2022-05-09 10:54 |
Anonymous (not verified) |
209.180.36.109 |
Sani Enterprise |
101 Ashworth Rd |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-09 |
Safet Derguti |
safetigo@hotmail.com |
Des Moines |
Polk |
Iowa |
Andrew Swanson |
Sandro Tadic |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andrew Swanson |
sanienterprise14@gmail.com |
Director of Operations |
Granger |
Dallas |
Iowa |
Andrew Swanson |
Sandro Tadic |
Signed |
471 |
2022-05-13 10:08 |
Anonymous (not verified) |
104.166.245.37 |
Juan Ramiro Rivas Perez |
6211 SW 5th Street. Des Moines IA 50315 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-02 |
Juan Ramiro Rivas Perez |
cecyperezv1982@icloud.com |
Des Moines |
Polk |
Iowa |
Carmen Perez |
Oscar Ramirez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Juan Ramiro Rivas Perez |
cecyperezv1982@icloud.com |
Secretary |
Des Moines |
Polk |
Iowa |
Carmen Perez |
Oscar Ramirez |
Signed |
478 |
2022-05-24 13:16 |
Anonymous (not verified) |
63.146.149.12 |
EBN CONSTRUCTION LLC |
314 NE 5TH ST, ANKENY IA 50021 |
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. |
2022-05-24 |
Juan J Perez Munoz |
ebnconstruction@icloud.com |
Des Moines |
Polk |
Iowa |
Jaime Leiva |
Kevin Pham |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Juan J Perez Munoz |
ebnconstruction@icloud.com |
Owner |
Des MOines |
Polk |
Iowa |
Jaime Leiva |
Kevin Pham |
Signed |
504 |
2022-06-30 17:18 |
Anonymous (not verified) |
209.180.36.109 |
Sani Enterprise |
101 Ashworth Rd |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-30 |
Timothy Roberts |
roberts.timoty2@gmail.com |
Des Moines |
Polk |
Iowa |
Sandro Tadic |
Andy Swanson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sandro Tadic |
sanienterprise14@gmail.com |
Owner |
Urbandale |
polk |
iowa |
Sandro Tadic |
Andy Swanson |
Signed |
507 |
2022-06-30 17:25 |
Anonymous (not verified) |
209.180.36.109 |
Sani Enterprise |
101 Ashworth Rd |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-30 |
Julia hernandez |
juliaherdz.1983@gmail.com |
Des Moines |
polk |
iowa |
Sandro Tadic |
Andy Swanson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sandro Tadic |
sanienterprise14@gmail.com |
Owner |
Urbandale |
polk |
iowa |
sandro tadic |
andy swanson |
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 |
540 |
2022-09-22 18:48 |
Anonymous (not verified) |
172.58.84.145 |
José j Castañeda lara |
1722 22st Des Moines iowa 50310 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-09-22 |
José j Castañeda lara |
jesuscastaneda28@gmail.com |
Des Moines |
Polk |
Iowa |
Joseph Powell |
Jesica Powell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
José j Castañeda lara |
jesuscastaneda28@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Joseph Powell |
Jesica Powell |
Signed |
551 |
2022-10-02 10:56 |
Anonymous (not verified) |
174.198.70.237 |
Des Moines Roofing Contractor |
2234 Highland St Des Moines, IA |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-10-02 |
Nancy Lopez |
nanoran3@gmail.com |
Des Moines |
Polk City |
IA |
Noe Ordaz |
Angie Florian |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nancy Lopez |
nanoran3@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Noe Ordaz |
Angie Florian |
Signed |
553 |
2022-10-03 15:32 |
Anonymous (not verified) |
165.206.254.105 |
Ski Mechanical Services |
729 Bell Ave. Des Moines, IA 50315 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-10-03 |
Terry Wave Konchalski |
skiwave79@gmail.com |
Des Moines |
Polk |
Iowa |
Melissa Kerr |
Charlie Ruperto |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Terry Wave Konchalski |
skiwave79@gmail.com |
Owner/President |
Des Moines |
Polk |
Iowa |
Melissa Kerr |
Charlie Ruperto |
Signed |
554 |
2022-10-03 15:44 |
Anonymous (not verified) |
75.162.176.251 |
SBM Construction Inc |
3023 1st 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. |
2022-09-03 |
Mike Guerrero |
service@fritzins.com |
Des Moines |
Polk |
Iowa |
David Fritz |
Matthew Fritz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mike Guerrero |
service@fritzins.com |
Owner |
Des Moines |
Polk |
Iowa |
David Fritz |
Matthew Fritz |
Signed |
577 |
2022-12-02 12:31 |
Anonymous (not verified) |
74.84.79.78 |
Juan A. Martinez-Salazar |
7085 Bloomfield Rd. 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. |
2022-01-02 |
Juan A. Martinez Salazar |
bananas94@icloud.com |
Des Moines |
Polk |
IA |
Racio Rodriguez |
Manuel Gonzalez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Juan A. Martinez- Salazar |
bananas94@icloud.com |
President |
Des Moines |
Polk |
IA |
Racio Rodriguez |
Manuel Gonzales |
Signed |
581 |
2022-12-09 11:23 |
Anonymous (not verified) |
74.84.79.78 |
Avila Gutters |
5901 SW 5th St. Des Moines, IA 50315 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-01 |
Enrique Avila Ceballos |
enrique86avila@gmail.com |
Des Moines |
Polk |
Iowa |
Michael O'Conner |
Ron Rand |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Enrique Avila Ceballos |
enrique86avila@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Michael O'Conner |
Ron Rand |
Signed |
582 |
2022-12-09 11:26 |
Anonymous (not verified) |
74.84.79.78 |
Diamond Does It LLC |
3945 38th St. Des Moines, IA 50310 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-01 |
Daimond Martinez |
diamonddoesitdsm@gmail.com |
Des Moines |
Polk |
Iowa |
Michael O'Conner |
Ron Rand |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Diamond Martinez |
diamonddoesitdsm@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Michael O'Conner |
Ron Rand |
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 |
588 |
2023-01-13 10:49 |
Anonymous (not verified) |
173.17.248.155 |
Cheri's Roofing |
1842 Glenwood Circle Des Moines, IA 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-13 |
Cheryl Martinez |
cheri6876@yahoo.com |
Des Moines |
Polk |
Iowa |
Jessica L Newton |
Thomas C Newton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cheryl Martinez |
cheri6876@yahoo.com |
Owner |
Des Moines |
Polk |
Iowa |
Jessica L Newton |
Thomas C Newton |
Signed |
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 |
598 |
2023-02-10 09:38 |
Anonymous (not verified) |
94.188.207.225 |
Y & M Cleaning Services Inc. |
4380 SE 15th 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. |
2023-02-10 |
Martine Martinez |
martinmtzmartinez@gmail.com |
Des Moines |
Polk |
Iowa |
Suzanne E Collier |
Andy Boyd |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Suzanne E Collier |
scollie1@amfam.com |
Non Related |
Altoona |
Polk |
IA |
Andy Boyd |
Martin Martinez |
Signed |
606 |
2023-02-20 20:55 |
Anonymous (not verified) |
94.188.205.168 |
Carlos Ortiz LLC |
4335 NE 23rd Ave Des Moines, IA 50317 Estados Unidos |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-02-20 |
Carlos Ortiz |
carlosoframing@gmail.com |
Des Moines |
Polk |
Iowa |
Luz picazo |
Brando ortiz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Carlos Ortiz |
carlosograming@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Luz picazo |
Brando Ortiz |
Signed |
609 |
2023-02-22 18:56 |
Anonymous (not verified) |
94.188.205.174 |
Roman construction |
3214 se 20th st, Des Moines, Iowa, 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2023-02-22 |
Jonathan roman |
romanconstruction21@outlook.com |
Des moines |
Polk |
Iowa |
Jonathan Roman |
Perla Roman |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Jonathan Roman |
romanconstruction21@outlook.com |
Owner |
Des moines |
Polk |
Iowa |
Jonathan roman |
Perla roman |
Signed |
612 |
2023-02-24 08:02 |
Anonymous (not verified) |
94.188.205.166 |
Ketter Household |
3517 Witmer Pkwy |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-02-24 |
Sarah Jones Ketter |
sarahajones09@gmail.com |
Des Moines |
IA |
United States |
Christopher Ketter |
Stacia Fuller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sarah Jones Ketter |
sarahajones09@gmail.com |
Same |
Des Moines |
IA |
United States |
Christopher Ketter |
Stacia Fuller |
Signed |
619 |
2023-03-06 09:02 |
Anonymous (not verified) |
94.188.207.229 |
Gaytan Framing LLC |
4745 NE 27th Ct Des Moines IA 50317 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-06 |
Jose Gaytan |
jose1988.jg8@gmail.com |
Des Moines |
Iowa |
United States |
Carla Gaytan |
Eduardo Vazquez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jose Gaytan |
jose1988.jg8@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Carla Gaytan |
Eduardo Vazquez |
Signed |
621 |
2023-03-08 07:53 |
Anonymous (not verified) |
94.188.207.223 |
Don Wyckoff Heating Inc. |
95 Highway 5, Carlisle, IA 50047 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-04 |
Michael T Johnson |
mikeyjay1968@gmail.com |
Des Moines |
Polk |
IA |
Brady Cooper |
Carey Cooper |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mike Johnson |
mikeyjay@gmail.com |
Sub-Contractor |
Des Moines |
Polk |
IA |
Brady Cooper |
Carey Cooper |
Signed |
631 |
2023-03-22 13:33 |
Anonymous (not verified) |
94.188.205.167 |
Prime Rock Finishing LLC |
440 NW 50th PL Des Moines Iowa 50313 |
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 |
Ludwing Paredes |
primerockfinishing@gmail.com |
Des Moines |
Polk |
Iowa |
x |
x |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ludwing Paredes |
primerockfinishing@gmail.com |
President |
Des Moines |
Polk |
Iowa |
x |
x |
Signed |
637 |
2023-03-23 15:53 |
Anonymous (not verified) |
94.188.207.229 |
Pacifica Health Services, LLC |
4911 SW 19th St, Des Moines, IA 50315 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-23 |
Jennifer Conner |
jconner@viahealthservices.com |
Des Moines |
Polk |
IA |
Jackie Hastings |
Amber Perdue |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kevin Babb |
kbabb@viahealthservices.com |
CEO |
Waukee |
Dallas |
IA |
Jackie Hastings |
Amber Perdue |
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 |
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 |
644 |
2023-03-31 08:47 |
Anonymous (not verified) |
94.188.205.175 |
HDEZ, LLC |
7500 Bloomfield Rd, Lot 91, Des Moines, IA 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-31 |
Antonio Rosales |
tonyh873@gmail.com |
Des Moines |
Polk |
Iowa |
Ronald Barton |
Scott Grimm |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Antonio Rosales |
tonyh873@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Ronald Barton |
Scott Grimm |
Signed |
647 |
2023-04-04 11:51 |
Anonymous (not verified) |
94.188.207.225 |
Ibarra's Construction LLC |
4125 56th Street Des Moines IA 50310 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-04 |
Serafin Orendain Rivera |
serafinorivera334@gmail.com |
Des Moines |
Polk |
Iowa |
Saul Orendain |
Maricela Pillado |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Matt Thompson |
mthompson@urscompliance.com |
Agent |
Minneapolis |
Hennepin County |
MN |
Maricela Pillado |
Saul Orendain |
Signed |
654 |
2023-04-18 11:13 |
Anonymous (not verified) |
94.188.205.168 |
Moon & Pasutti Tile, LLC |
3501 SW 9th Street, Des Moines, IA 50315 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-18 |
Robert Michael Pasutti |
robpasutti@gmail.com |
Des Moines |
Polk |
IA |
Sharon Marie Pasutti |
Michael Anthony Daniel Pasutti |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Michael Pasutti |
robpasutti@gmail.com |
Co-Owner |
Des Moines |
Polk |
IA |
Sharon Marie Pasutti |
Michael Anthony Daniel Pasutti |
Signed |