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Rejection of Workers' Compensation or Employers' Liability Coverage

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# Submitted User IP address Name of Corporation: Address of Corporation Home Office: Statement 1 Agreement: Statement 2 Agreement: Statement 3 Agreement: Statement Agreement: Check Either Alternative (1) or (2): Date: Full Name of Individual: Email: City of Residence: County of Residence: State of Residence: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Agreement: Alternative Selection: Full Name of Authorized Agent: Email of Authorized Agent: Relationship to Corporation of Authorized Agent: City of Residence: County of Residence: State: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Indication:
286 2021-07-10 13:16 Anonymous (not verified) 69.57.205.10 Marquis Aviation, Inc 845 E. Redwood Cir. 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. 2021-07-10 Robert Wescott Cantrell rcr4@comcast.net Hanford Kings CA Shirley J. Loney Joel L. Meyer Signed (1) The corporation rejects the employers’ liability coverage. Robert W. Cantrell rcr4@comcast.net Secretary Hanford Kings CA Shirley J. Loney Joel L. Meyer Signed
335 2021-09-16 17:22 Anonymous (not verified) 64.142.5.50 Electrious Inc DBA Clean Tech 1110 Alhambra Ave Martinez CA 94533. 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. 2021-08-26 Robert Lemos robbie.lemos@clean.tech San Ramon Contra Costa County CA Teresa Leibnitz Greg Vermeulen Signed (1) The corporation rejects the employers’ liability coverage. Robbie Lemos robbie.lemos@clean.tech CEO San Ramon Contra Costa County CA Teresa Leibnitz Greg Vermeulen Signed
520 2022-07-23 14:19 Anonymous (not verified) 69.57.205.10 Marquis Aviation, Inc 845 E. Redwood Circle I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-23 Robert Wescott Cantrell marquisaviationinc@yahoo.com Hanford Kings CA Shirley J. Loney Joel L. Meyer Signed (1) The corporation rejects the employers’ liability coverage. Robert W. Cantrell marquisaviationinc@yahoo.com Secretary Hanford Kings CA Shirley J. Loney Joel L. Meyer Signed
700 2023-06-22 11:03 Anonymous (not verified) 94.188.207.229 WIT Systems Corporation 313 Brentwood Dr NE, Cedar Rapids, IA 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. (1) I reject the employers’ liability coverage. 2023-06-22 DOUGLAS K WILLIAMS dkwilliams@witsystems.com Cedar Rapids IA Linn CT Patrick Gavin Kaley Gavin Signed (1) The corporation rejects the employers’ liability coverage. DOUGLAS K WILLIAMS dkwilliams@witsystems.com President CEDAR RAPIDS IA United States Patrick Gavin Kaley Gavin Signed
336 2021-09-16 18:53 Anonymous (not verified) 64.142.5.50 Electrious Inc DBA Clean Tech 1110 Alhambra Ave Martinez CA 94533. 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. 2021-08-26 Petr Brazdil petr.brazdil@clean.tech Trida Spojencu Brno Czechia in Europe Robbie Lemos Teresa Leibnitz Signed (1) The corporation rejects the employers’ liability coverage. Robbie Lemos robbie.lemos@clean.tech CEO SAN RAMON Contra Costa County CA Robbie Lemos Teresa Leibnitz Signed
441 2022-04-11 13:15 Anonymous (not verified) 75.162.175.12 Castro construction LLC 1712 carpenter av desmoines Iowa 50314 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-11 Carlos Alberto castro Alcántara castrodvxhd@gmail.com Estados Unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe padilla bonilla Signed (1) The corporation rejects the employers’ liability coverage. Carlos Alberto castro Alcántara castrodvxhd@gmail.com Owner Estados unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe Padilla Bonilla Signed
442 2022-04-11 13:15 Anonymous (not verified) 75.162.175.12 Castro construction LLC 1712 carpenter av desmoines Iowa 50314 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-11 Carlos Alberto castro Alcántara castrodvxhd@gmail.com Estados Unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe padilla bonilla Signed (1) The corporation rejects the employers’ liability coverage. Carlos Alberto castro Alcántara castrodvxhd@gmail.com Owner Estados unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe Padilla Bonilla Signed
443 2022-04-11 13:15 Anonymous (not verified) 75.162.175.12 Castro construction LLC 1712 carpenter av desmoines Iowa 50314 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-11 Carlos Alberto castro Alcántara castrodvxhd@gmail.com Estados Unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe padilla bonilla Signed (1) The corporation rejects the employers’ liability coverage. Carlos Alberto castro Alcántara castrodvxhd@gmail.com Owner Estados unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe Padilla Bonilla Signed
450 2022-04-20 13:42 Anonymous (not verified) 96.85.81.137 D&K Harvesting Inc. P.o Box 1347 LaBelle Fl 33975 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-20 James Larry Marsh Jr larrym3041@aol.com Fort myers Lee Florida Anita Coronado Christy Pequeno Signed (2) The corporation declines to reject the employers’ liability coverage. James Larry Marsh Jr larrym3041@aol.com Owner Fort myers Lee Florida Anita Coronado Christy Puequeno Signed
20 2019-12-30 09:39 Anonymous (not verified) 207.191.194.182 LA Trends Addict Inc 1200 N CENTER POINT 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. 2019-10-07 Laura Frey fcrentals1@gmail.com HIAWATHA Linn IA Traci Lyons Allie DeVore Signed (1) The corporation rejects the employers’ liability coverage. Laura Frey fcrentals1@gmail.com Owner HIAWATHA Linn IA Traci Lyons Allie DeVore Signed
21 2019-12-30 11:28 Anonymous (not verified) 207.191.194.182 Bob Stephen Motors Inc 324 W Main St, Manchester IA 52057 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2019-11-05 Paul Roussell twyladetrich@gmail.com MANCHESTER DELAWARE IA Traci Lyons Allie DeVore Signed (1) The corporation rejects the employers’ liability coverage. Heidi Roussell twyladetrich@gmail.com Vice President Manchester DELAWARE IA Traci Lyons Allie DeVore Signed
22 2019-12-30 11:30 Anonymous (not verified) 207.191.194.182 Bob Stephen Motors Inc 324 West Main St, Manchester IA 52057 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2019-11-05 Heidi Roussell twyladetrich@gmail.com Manchester DELAWARE IA Traci Lyons Allie DeVore Signed (1) The corporation rejects the employers’ liability coverage. Paul Roussell twyladetrich@gmail.com President MANCHESTER Delaware IA Traci Lyons Allie DeVore Signed
37 2020-02-06 15:49 Anonymous (not verified) 100.42.95.100 Matthew Saboe 2075 330th St, Spencer IA 51301 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. 2020-02-06 Matthew Saboe galmgirl@gmail.com Spencer Clay IA Laura Ashley Tauscher Diane Kimball Signed (1) The corporation rejects the employers’ liability coverage. Matthew Saboe galmgirl@gmail.com Owner Spencer Clay IA Laura Ashley Tauscher Diane Kimball Signed
45 2020-03-10 10:24 Anonymous (not verified) 204.141.214.180 Shamrock Screenprinting Inc 2710 Granite Ct NE I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-03-10 Lori Handley lori.handley@aol.com Cedar Rapids Linn IA David Handley Beth Barta Signed (1) The corporation rejects the employers’ liability coverage. Lori Handley lori.handley@aol.com VP Cedar Rapids Linn IA David Handley Beth Barta Signed
46 2020-03-10 10:26 Anonymous (not verified) 204.141.214.180 Shamrock Screenprinting Inc 2710 Granite Ct NE I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-03-10 David Handley davehandley53@gmail.com Cedar Rapids Linn IA Lori Handley Beth Barta Signed (1) The corporation rejects the employers’ liability coverage. Lori Handley Lori.handley@aol.com VP Cedar Rapids Linn IA Lori Handley Beth Barta Signed
75 2020-04-29 11:07 Anonymous (not verified) 107.77.206.22 ACR Construction, Inc 7330 NW 21 St. 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. 2020-04-29 Andre Sean Drost andre.drost@acr-construction-inc.com Ankeny Polk IA Heidi Smith Jeff Smith Signed (1) The corporation rejects the employers’ liability coverage. Candace Drost acrdrost@hotmail.com President Ankeny Polk IA Heidi Smith Jeff Smith 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
98 2020-07-11 16:34 Anonymous (not verified) 50.83.184.81 Paradigm Construction LLC 1847 nw 90th st Clive, IA 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-07-06 Jonathon Richard Curtis joncurtis15@gmail.com Des Moines Polk IA Yolanda Curtis Susan Brooker Signed (2) The corporation declines to reject the employers’ liability coverage. Ryan Shabino ryan@prdgmconstruction.com Contractor Clive Polk IA Yolanda Curtis Susan Brooker Signed
99 2020-07-12 13:29 Anonymous (not verified) 207.32.58.202 Subject Enterprise, Inc. 165 210th St Wesley, IA 50483 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. 2020-07-12 Coda Subject subjectenterprise@gmail.com Britt Hancock IA Keri Byom Steve Schlichting Signed (1) The corporation rejects the employers’ liability coverage. Coda Subject subjectenterprise@gmail.com Owner Britt Hancock IA Keri Byom Steve Schlichting Signed
100 2020-07-14 19:08 Anonymous (not verified) 208.90.8.234 Humboldt County Agricultural 311 N 6th Ave, P.O. Box 391, Humboldt, IA 50548 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. 2020-07-18 Jeff Haselhuhn gjhaselhuhn@gmail.com Humboldt Humboldt IA Marva Anderson Jeff Halverson Signed (1) The corporation rejects the employers’ liability coverage. Marva Anderson info@humboldtcountyfair.com Business Manager Humboldt 81 81 Marva Anderson Jeff Halverson Signed
102 2020-07-19 14:42 Anonymous (not verified) 208.90.8.234 Humboldt County Agricultural Society 311 N 6th Ave P.O. Box 391, Humboldt, IA 50548 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. 2020-07-19 Paul Davis dfs72@yahoo.com Humboldt Humboldt IA Marva Anderson Paul Davis Signed (1) The corporation rejects the employers’ liability coverage. Humboldt County Agricultural Society info@humboldtcountyfair.com Business Manager Humboldt 81 IA Marva Anderson Jeff Halverson Signed
105 2020-07-24 18:21 Anonymous (not verified) 74.115.101.23 Humboldt County Agricultural Society 311 N 6th Ave P.O. Box 391, Humboldt, IA 50548 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. 2020-07-24 Kevin Cordray kwcordray@gmail.com Humboldt Humboldt IA Marva Anderson Jeff Halverson Signed (1) The corporation rejects the employers’ liability coverage. Humboldt County Agricultural Society info@humboldtcountyfair.com Business Manager Humboldt Humboldt IA Marva Anderson Jeff Halverson Signed
115 2020-09-08 09:48 Anonymous (not verified) 184.80.177.137 Beyond Builders LLC 206 Culver Road NE, Hopkinton, IA 52237 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-08 John Eiben ginger_bread_man@msn.com HOPKINTON Delaware IA Derrick Parsons Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. John Eiben ginger_bread_man@msn.com Owner Hopkinton Delaware Iowa Derrick Parsons Derrick Parsons Signed
122 2020-10-05 15:21 Anonymous (not verified) 173.24.190.134 Greg Haldin Construction, Inc. PO Box 387, Sioux Rapids, IA 50585 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-10-06 Greg Haldin ghconstruction@live.com Sioux Rapids Buena Vista IA Candie Clark Scott Wirtz Signed (1) The corporation rejects the employers’ liability coverage. Greg Haldin ghconstruction@live.com President Sioux Rapids Buena Vista IA Candie Clark Scott Wirtz Signed
125 2020-10-26 16:33 Anonymous (not verified) 162.253.44.212 Gutter Filter Specialists Inc 1805 Red Fox Way Marion, IA 52302 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-10-26 Richard L Mellor rickmellor88@gmail.com Marion Linn IA Katie Luehrsmann Melissa Lown Signed (1) The corporation rejects the employers’ liability coverage. Richard L Mellor rickmellor88@gmail.com President Marion Linn IA Katie Luehrsmann Melissa Lown Signed
128 2020-10-29 07:51 Anonymous (not verified) 74.84.91.178 J & J Drywall LLC 1277 Elm Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-10-27 Jeff Frick frickdbq@gmailc.com Dubuque Dubuque IA Brenda Lewis Gabe Drewelow Signed (1) The corporation rejects the employers’ liability coverage. Jeff Frick frickdbq@gmailc.com president Dubuque Dubuque Iowa Brenda Lewis Gabe Drewelow Signed
135 2020-11-20 11:05 Anonymous (not verified) 208.95.1.97 Burds Communities Inc. 606 S 3rd Street, 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. 2020-11-20 Todd Burds burdshousing@yahoo.com Peosta Dubuque IA Paula Fitzgerald Jena Wilwert Signed (1) The corporation rejects the employers’ liability coverage. Todd Burds burdshousing@yahoo.com President Peosta Dubuque IA Paula Fitzgerald Jena Wilwert Signed
136 2020-11-20 11:06 Anonymous (not verified) 208.95.1.97 Burds Communities Inc. 606 S 3rd Street, 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. 2020-11-20 Tim Burds burdshousing@yahoo.com Peosta Dubuque IA Paula Fitzgerald Jena Wilwert Signed (1) The corporation rejects the employers’ liability coverage. Tim Burds burdshousing@yahoo.com Vice President Peosta Dubuque IA Paula Fitzgerald Jena Wilwert Signed
138 2020-11-24 14:11 Anonymous (not verified) 173.215.17.41 Dohrmann Enterprises, Inc 2478 260th Ave. DeWitt, Iowa 52742 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-11-24 Joel Dohrmann dohrmannpnh@gmail.com DE WITT Clinton IA Susanne Owen Daron Oberbroecking Signed (1) The corporation rejects the employers’ liability coverage. Susanne Owen sowen@ohnward.com none Camanche Clinton Iowa Joel Dohrmann Daron Oberbroecking Signed
144 2020-12-04 12:02 Anonymous (not verified) 184.80.177.137 Arlen, LLC 322 6th St SE - Dyersville, Iowa 52040 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. 2020-12-04 Dan Arlen jheims@english-insurance.com Dyersville IA IA Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Joyce Heims joyce.heims1@gmail.com agent Dyersville IA IA Derrick Parsons Joyce Heims Signed
146 2020-12-22 08:48 Anonymous (not verified) 207.155.115.120 Kafer Lawn Care 206 frentress dr Farley, IA 52046 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-22 Benjamin Terry Hayes benhayes1800@gmail.com Epworth Dubuque IA Adam Kafer Jeffery Sisler Signed (1) The corporation rejects the employers’ liability coverage. Benjamin Terry Hayes benhayes1800@gmail.com Owner Epworth Dubuque IA Adam Kafer Jeffery Sisler Signed
149 2020-12-31 14:59 Anonymous (not verified) 216.81.153.249 S&A Holdings LLC 115 N 2nd Street, Fort Dodge, IA 50501 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. 2020-12-21 Surinder Kumar NONE@GMAIL.COM Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Surinder Kumar NONE@GMAIL.COM Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
150 2020-12-31 15:00 Anonymous (not verified) 216.81.153.249 S&A Holdings LLC 115 N 2nd Street, Fort Dodge, IA 50501 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. 2020-12-21 Amritpal Singh amritaust1@gmail.com Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Amritpal Singh amritaust1@gmail.com Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
151 2021-01-01 11:26 Anonymous (not verified) 75.162.130.160 The Product Boss LLC 20 Mountain Way, West Orange, NJ 07052 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-01 Minna Khounlo-Sithep minna@theproductboss.com Ankeny IA IA Nalinh Sithep Suzzan Khounlo Signed (1) The corporation rejects the employers’ liability coverage. Minna Khounlo-Sithep minnaks@gmail.com Co-Owner Ankeny IA IA Nalinh Sithep Suzzan Khounlo Signed
155 2021-01-06 15:50 Anonymous (not verified) 216.81.153.249 Al's Inc DWB CW&T 1509 Richland Drive, Storm Lake, IA 5058 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. 2020-12-29 Robert Bauer NONE@GMAIL.COM Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Robert Bauer NONE@GMAIL.COM Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
156 2021-01-06 15:52 Anonymous (not verified) 216.81.153.249 Al's Inc DWB CW&T 1509 Richland Drive, Storm Lake, IA 5058 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. 2020-12-29 Jon Bauer NONE@GMAIL.COM Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Jon Bauer None@gmail.com Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
157 2021-01-06 15:53 Anonymous (not verified) 216.81.153.249 Al's Inc DWB CW&T 1509 Richland Drive, Storm Lake, IA 5058 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. 2020-12-29 April Coleman NONE@GMAIL.COM Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. April Coleman None@gmail.com Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
158 2021-01-06 15:54 Anonymous (not verified) 216.81.153.249 Al's Inc DWB CW&T 1509 Richland Drive, Storm Lake, IA 5058 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. 2020-12-29 Julie Deucker NONE@GMAIL.COM Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Julie Duecker None@gmail.com Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
159 2021-01-12 09:00 Anonymous (not verified) 72.13.20.192 RTA TRUCKING LLC 31504 E Worthington Rd, Worthington, IA 52078 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. 2020-01-12 Kirk Pleggenkuhle dba Pleggenkuhle Pride Inc. kirkpleggenkuhle@gmail.com Mingo Jasper IA Rod Jaeger Jennie Jaeger Signed (1) The corporation rejects the employers’ liability coverage. Jennie Jaeger rtatruck@gmail.com office manager Worthington IA United States Rod Jaeger Kirk Pleggenkuhle Signed
163 2021-01-20 11:08 Anonymous (not verified) 173.233.46.58 Wasmer Post 241 Department of Iowa dba The American Legion 110 Plymouth St SW, Le Mars, IA 51031 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 Kim Wittmar mrkmjm@yahoo.com Le Mars Plymouth iA Muriel J. MIller Richard P. Miller Signed (1) The corporation rejects the employers’ liability coverage. Gary L. Konz claim_buster@yahoo.com Financial Officer Le Mars Plymouth IA Muriel J. Miller Richard P. Miller Signed
164 2021-01-20 11:11 Anonymous (not verified) 173.233.46.58 Wasmer Post 241, Department of Iowa dba The American Legion 110 Plymouth St SW, Le Mars, IA 51031 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 Andrew M. Schultze mrkmjm@yahoo.com Le Mars Plymouth IA Muriel J. Miller Richard P. Miller Signed (1) The corporation rejects the employers’ liability coverage. Gary L. Konz claim_buster@yahoo.com Financial Officer Le Mars Plymouth IA Muriel J. Miller Richard P. Miller Signed
165 2021-01-20 11:14 Anonymous (not verified) 173.233.46.58 Wasmer Post 241, Department of Iowa dba The American Legion 110 Plymouth St SW, Le Mars, IA 51031 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 Matthew Larson mrkmjm@yahoo.com Alton Sioux IA Muriel J. Miller Richard P. Miller Signed (1) The corporation rejects the employers’ liability coverage. Gary L. Konz claim_buster@yahoo.com Financial Officer Le Mars Plymouth IA Muriel J. Miller Richard P. Miller Signed
166 2021-01-21 08:52 Anonymous (not verified) 66.102.212.10 English River Transport, Inc. 2015 Highway 22, Kalona, IA 52247 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-13 James A Yoder fisheria@kctc.net Kalona Washington IA Christian Swartzentruber Judy Showalter Signed (1) The corporation rejects the employers’ liability coverage. James A Yoder christian@fisherins.com President Kalona Washington IA Christian Swartzentruber Judy Showalter Signed
175 2021-02-01 11:20 Anonymous (not verified) 216.51.132.207 VONDERHAAR CONSTRUCTION 33181 OSTERDOCK RD GUTTENBERG IA 52052 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. 2020-12-28 ROBIE VONDERHAAR nicole@cioia.com GUTTENBERG CLAYTON IA JERRY J ROCHFORD NICOLE L PARKER Signed (1) The corporation rejects the employers’ liability coverage. ROBIE VONDERHAAR NICOLE@CIOIA.COM OWNER Guttenberg CLAYTON IA JERRY J ROCHFORD NICOLE L PARKER Signed
185 2021-02-23 15:16 Anonymous (not verified) 173.29.151.168 TONY V'S PAINTING 2316 CRESCENT AVE DAVENPORT, IA 52804 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-02-23 ANTHONY VANCE ANTHONYJV1977@GMAIL.COM DAVENPORT SCOTT IA TONY BURKHART RICHARD MILLER-VANCE Signed (1) The corporation rejects the employers’ liability coverage. ANTHONY VANCE ANTHONYJV1977@GMAIL.COM OWNER DAVENPORT SCOTT IA TONY BURKHART RICHARD MILLER-VANCE 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
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
248 2021-04-29 09:59 Anonymous (not verified) 173.31.147.225 BOJI CUSTOM METAL WORKS INC 402 E 4TH ST SPENCER, IA 51301 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. 2021-04-23 SCOTT PYLE scottpyle98@hotmail.com FOSTORIA CLAY IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The corporation rejects the employers’ liability coverage. SCOTT PYLE joel@walkerinsuranceia.com PRESIDENT FOSTORIA CLAY IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
249 2021-05-03 09:29 Anonymous (not verified) 107.77.206.82 Cassatt drywall 3235 woodland dr leclaire 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. 2021-05-02 James Jansen james.jansen23@yahoo.com Davenport Scott IA Kara kelting Jake harris Signed (1) The corporation rejects the employers’ liability coverage. Steve cassatt cassattdrywall@gmail.com Owner Leclaire Scott IA Kara kelting Jake harris Signed
251 2021-05-04 13:39 Anonymous (not verified) 159.242.43.24 Parrott Distributing, Inc 1429 16th Ave SE, Lemars, IA 51031 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. 2021-05-04 Jason Parrott jlparrott@premieronline.net Lemars Plymouth IA Jenny McIntyre Josh Olson Signed (1) The corporation rejects the employers’ liability coverage. Jason Parrott jlparrott@premieronline.net President Lemars Plymouth IA Jenny McIntyre Josh Olson Signed